Monday, August 22, 2016

Billing Guide for Bilateral surgeries with example


A. General

Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day.

The terminology for some procedure codes includes the terms “bilateral” (e.g., code 27395; Lengthening of the hamstring tendon; multiple, bilateral.) or “unilateral or bilateral” (e.g., code 52290; cystourethroscopy; with ureteral meatotomy, unilateral or bilateral). The payment adjustment rules for bilateral surgeries do not apply to procedures identified by CPT as “bilateral” or “unilateral or bilateral” since the fee schedule reflects any additional work required for bilateral surgeries.
Field 22 of the MFSDB indicates whether the payment adjustment rules apply to a surgical procedure.



B. Billing Instructions for Bilateral Surgeries

If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral), physicians must report the procedure with modifier “-50.” They report such procedures as a single line item. (NOTE: This differs from the CPT coding guidelines which indicate that bilateral procedures should be billed as two line items.)
If a procedure is identified by the terminology as bilateral (or unilateral or bilateral), as in codes 27395 and 52290, physicians do not report the procedure with modifier “-50.”



C. Claims Processing System Requirements

Carriers must be able to:

1. Identify bilateral surgeries by the presence on the claim form or electronic submission of the “-50” modifier or of the same code on separate lines reported once with modifier “-LT” and once with modifier “-RT”;

2. Access Field 34 or 35 of the MFSDB to determine the Medicare payment amount;

3. Access Field 22 of the MFSDB:

• If Field 22 contains an indicator of “0,” “2,” or “3,” the payment adjustment rules for bilateral surgeries do not apply. Base payment on the lower of the billed amount or 100 percent of the fee schedule amount (Field 34 or 35) unless other payment adjustment rules apply.

NOTE: Some codes which have a bilateral indicator of “0” in the MFSDB may be performed more than once on a given day. These are services that would never be considered bilateral and thus should not be billed with modifier “-50.” Where such a code is billed on multiple line items or with more than 1 in the units field and carriers have determined that the code may be reported more than once, bypass the “0” bilateral indicator and refer to the multiple surgery field for pricing;

• If Field 22 contains an indicator of “1,” the standard adjustment rules apply. Base payment on the lower of the billed amount or 150 percent of the fee schedule amount (Field 34 or 35). (Multiply the payment amount in Field 34 or 35 for the surgery by 150 percent and round to the nearest cent.)

4. Apply the requirements §§40 - 40.4 on global surgeries to bilateral surgeries; and

5. Retain the “-50” modifier in history for any bilateral surgeries paid at the adjusted amount.

(NOTE: The “-50” modifier is not retained for surgeries which are bilateral by definition such as code 27395.)

No comments:

Post a Comment

Most read colonoscopy CPT codes