Payment of Bilateral Procedures - 150% of allowed amount

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

Part A Providers

Provider Types Affected Method II Critical Access Hospitals (CAH) submitting claims to Medicare contractors (Fiscal Intermediaries (FIs) and/or A/B Medicare Administrative Contractors (A/B MACs)) for bilateral procedure services provided to Medicare beneficiaries.

Impact to You This article is based on Change Request (CR) 6526 which implements payment for bilateral procedures performed in Method II Critical Access Hospitals (CAHs), in cases where the physician reassigns billing rights to the Method II CAH.

What You Need to Know Bilateral procedures are procedures performed on both sides of the body during the same operative session. Medicare makes payment for bilateral procedures based on the 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. Modifier 50 is used for bilateral procedures and this article provides information on claims submission for these procedures. CR 6526 implements the 150 percent payment adjustment for bilateral procedures.

What You Need to Do See the Background and Additional Information Sections of this article for further details regarding these changes.