How to bill bilateral procedure and get paid

Payment of Bilateral Procedures in a Method II Critical Access Hospital (CAH)


BackgroundThe Social Security Act (Section 1834(g)(2)(B); see http://www.ssa.gov/OP_Home/ssact/title18/1834.htm on the Internet) states that professional services included within outpatient Critical Access Hospital (CAH) services, will be paid 115 percent of such amounts as would otherwise be paid under this part if such services were not included in the outpatient CAH services. The Centers for Medicare & Medicaid Services (CMS) establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. See 42 CFR 414.40 at http://edocket.access.gpo.gov/cfr_2007/octqtr/pdf/42cfr414.42.pdf on the Internet. This includes the use of the 50 modifier (bilateral procedure).

Physicians and non-physician practitioners billing on type of bill (TOB) 85X for professional services rendered in a Method II CAH have the option of reassigning their billing rights to the CAH. When the billing rights are reassigned to the Method II CAH, payment is made to the CAH for professional services (revenue codes (RC) 96X, 97X or 98X).

Bilateral procedures are procedures performed on both sides of the body during the same operative session. Medicare makes payment for bilateral procedures based on lesser of the actual charges or 150 percent of the Medicare Physician Fee Schedule (MPFS) amount when the procedure is authorized as a bilateral procedure. CR 6526 implements the 150 percent payment adjustment for bilateral procedures. Medicare contractors use payment policy indicators associated with certain procedures in the MPFS in processing claims and determining payment.

Bilateral procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is authorized as a bilateral procedure and is billed on TOB 85X with revenue code (RC) 96X, 97X or 98X and the 50 modifier (bilateral procedure). Modifier 50 applies to bilateral procedures performed on both sides of the body during the same operative session. When a procedure is identified by the terminology as bilateral or unilateral or bilateral, the 50 modifier is not reported.

If a procedure is authorized for the 150 percent payment adjustment for bilateral procedures (payment policy indicator 1), the procedure should be reported on a single line item with the 50 modifier and one service unit. Whenever the 50 modifier is appended, the appropriate number of service units is one.

Modifiers LT (left side) and RT (right side) are not to be reported when the 50 modifier applies. Claims with the LT and RT modifiers will be returned to the provider (RTP) when modifier 50 applies. See the Medicare Claims Processing Manual, Chapter 4, section 20.6 at http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf on the CMS website for more information on the use of the 50, LT and RT modifiers.

If a procedure can be billed as bilateral but is not authorized for the 150 percent payment adjustment for bilateral procedures (payment policy indicator 3), the procedure is to be reported on a single line item with the 50 modifier and one service unit. Payment is made based on the lesser of the actual charges or 100% of the MPFS amount for each side of the body.

The January 2010 Integrated Outpatient Code Editor (IOCE) specifications will include a change to edit 74 (units greater than one for bilateral procedures billed with modifier 50). At that time, claims submitted on TOB 85X with revenue code (RC) 96X, 97X or 98X , a Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code with a bilateral indicator of ‘1’ or ‘3’, modifier 50 and more than one service unit on the same line will be returned to the provider.

Medicare uses the bilateral surgery payment policy indicators on the MPFS to determine if the 150 percent payment adjustment is payable for a specific HCPCS/CPT code. The MPFS database is located at http://www.cms.hhs.gov/apps/ama/license.asp?file=/pfslookup/02_PFSsearch.asp on the CMS website. Medicare contractors have access to the payment policy indicators via the Physician Fee Schedule Payment Policy Indicator File in their claims processing systems.

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