Bilateral Procedures

Reimbursement Policy:

Bilateral Procedures (Modifiers 50, LT, RT)

Effective Date:

December 11, 2007

Last Revised Date:

December 18, 2015

Purpose:

Provide guidelines for the reimbursement of bilateral procedures. This policy applies to professional providers.

Scope:

All products are included, except

• Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
• COB

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

• Bilateral Procedures:Surgical operations performed on both the right and left side of a patient's body during the same operative session requiring separate sterile fields and a separate surgical incision (from www.cms.gov).
• Modifier 50: Bilateral Procedure.
• Modifier LT/RT: Used to identify procedures performed on the Left Side/Right Side, respectively, of the body. To be used when bilateral surgery rules do not apply.

Policy:

In accordance with Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS), procedure codes described as unilateral procedures that can be performed on both sides of the body by the same provider, for the same patient, during the same surgical session will be considered for bilateral payment adjustment when appropriately appended with Modifier 50.

Horizon BCBSNJ shall align with CMS in determining procedure codes that are eligible for bilateral payment adjustment.

Horizon BCBSNJ shall not reimburse CPT or HCPCS codes appended with bilateral modifiers when:

• The procedure codes are defined by CPT/HCPCS as primarily bilateral or a bilateral service, since the allowed amounts for these procedure codes are already inclusive of the bilateral procedure.
• Appended to a bilateral procedure performed on a different area of the right and left sides of the body (modifier RT/LT).
• Appended to a surgical CPT code in which the description contains the words “one” or “both”.

Procedure:

In accordance with CMS guidelines, Horizon BCBSNJ shall reimburse bilateral procedures as noted below:

MPFSDB IndicatorAppend Modifier 50/LT/RTBilateral Adjustment Applies?Reimbursement

0LT/RTNoOne side 100%; other side 50% of applicable Horizon BCBSNJ fee schedule; Reimburses one unit of each regardless of units billed.

150YesAllows 150% of the applicable Horizon BCBSNJ fee schedule.

2LT/RTNoProcedure code already priced as bilateral; reimburses one unit regardless of number of units billed at Horizon BCBSNJ applicable fee schedule

3LT/RTNoReimburses each side at 100% of applicable Horizon BCBSNJ fee schedule

9N/ANoCodes billed with modifier 50/LT/RT shall deny.

In instances where the provider is participating, based on member benefits, copayment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement/li>
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

Policy 018_v1.0_12182015