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PAP258

Bilateral Procedures


Provider Administrative Policy

Section
Claims Submission
Policy Date
February 2008
Status/Date
Revised/November 2012
Provider Type(s)
Ambulatory Surgery Centers   Hospitals   Physician   Podiatrists  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Policy

Bilateral Procedures

Bilateral procedures performed during the same operative session should be identified by adding modifier 50 to the appropriate five digit CPT code.  Blue Cross of Idaho will review claims for coding accuracy according to CPT coding and industry standards.  Please submit bilateral procedures to Blue Cross of Idaho as outlined below.

Physicians and Ambulatory Surgical Centers:
Identify the procedure performed using CPT coding guidelines. Append modifier 50 to the CPT codes representing bilateral services. Submit a single claim representing all services to Blue Cross of Idaho. Bilateral procedures are reimbursed according to the following guidelines:

1st bilateral procedure = 150 percent of the fee schedule allowance or your billed charge, whichever is less.

2nd bilateral procedure = 150 percent X 50 percent = 75 percent of the fee schedule allowance or your billed charge, whichever is less.

  1. When billing two bilateral procedures:
    • Primary bilateral = 150 percent of the fee schedule allowance for the procedure
    • Secondary bilateral = 75 percent of the fee schedule allowance for the  procedure;150 percent   X 50 percent = 75 percent
  2. When billing a primary, non-bilateral procedure and a secondary bilateral procedure:
    • Primary procedure = 100 percent of the fee schedule allowance for the procedure
    • Secondary bilateral procedure = 75 percent of the fee schedule allowance for the procedure; 150 percent X 50 percent = 75 percent
  3. When billing a primary bilateral procedure and a secondary bilateral procedure:
    • Primary bilateral = 150 percent of the fee schedule allowance for the procedure
    • Secondary procedure = 50 percent of the fee schedule allowance for the procedure

 Example: Billed Procedures: 

  • 31255-50
  • 31276-51
  • 31267-51

For the above example, the primary procedure is 31255-50 and allowed at 150 percent of the fee schedule allowance or billed charges, whichever is less. All remaining procedures are allowed at 50 percent of the fee schedule allowance.

Note: The bilateral procedure is not always the primary procedure.

Example: Billed Procedures: 

  • 30140-51, 50
  • 30520
  • 29881-51

For the above example, the primary procedure is 30520 and allowed at 100 percent of the fee schedule allowance. The secondary procedure is 30140-50 and allowed at 150 percent X 50 percent resulting in a reimbursement of 75 percent of the fee schedule allowance. The third procedure, 29881, is allowed at 50 percent of the fee schedule allowance.

Ambulatory Surgery Centers please refer to PAP257 for multiple procedure guidelines.

Hospitals:

For Hospitals, Blue Cross of Idaho will use the CMS National Physician Fee Schedule Relative Value File (NPFSRVF) to determine whether or not a procedure is a valid bilateral procedure. We price the allowance for bilateral procedures with a status of '1' or '3' at 150% of the hospital's contracted fee schedule allowance or billed charges, whichever is less.

For codes not normally discounted by Outpatient Prospective Payment System (OPPS)*, hospitals may bill two line items and use the right (RT) and left (LT) modifiers to receive the full allowance. Examples of these codes include casting procedures and radiology services.

Please bill only one unit per surgical procedure. If your office performed bilateral procedures, please append a modifier 50 on a singular line of RT/LT on two lines.

*any OPPS status indicators other that 'T'

Note: Services with no maximum allowance in your hospital fee schedule will be reimbursed based on the negotiated default discount as stated in your provider contract.  Bilateral procedure discounts will not be applied to these line items.

Radiology:
When providing appropriate bilateral radiology services, please use the right (RT) and left (LT) modifiers. Bilateral radiology services billed with modifier 50 may result in reduced reimbursement.  When right (RT) and left (LT) modifiers are submitted with radiology codes (70010-79999), modifier 51 is not required.


Policy History

Date Action Reason
November 2012 Revised Clarified hospital pricing
January 2010 Moved Moved from PAP509
July 2009 Revised Policy rewrite

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