Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes on the UnitedHealthcare Bilateral Eligible Procedures Policy List describe unilateral procedures that can be performed on both sides of the body during the same session by the Same Individual Physician or Other Qualified Health Care Professional. CPT or HCPCS codes with bilateral in their intent or with bilateral written in their description should not be reported with the bilateral modifier 50, or modifiers LT and RT, because the code is inclusive of the Bilateral Procedure.
For the purpose of this policy, the Same Individual Physician or Other Qualified Health Care Professional is the same individual rendering health care services reporting the same Federal Tax Identification number.
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Q: How should CPT or HCPCS codes such as for an excision of a lesion be billed when they are performed on both sides of the body and are not CMS bilateral eligible?
A: An excision of a lesion is not truly bilateral. It should be billed with units, rather than the bilateral modifier.
Q: If a code has the term 'bilateral' in its definition, can it be reported with modifier 50?
A: No. For example, if a CPT code includes the term 'bilateral' and is inherently a bilateral procedure, then the code does not appear on UnitedHealthcare's Bilateral Eligible Procedures Policy List and may not be reported with modifier 50.
Q: If a code has the term 'bilateral' in its definition, yet the procedure was only performed on one side, how should this be reported?
A: If a code exists for the comparable unilateral procedure, report the appropriate unilateral code. If a code does not exist for the comparable unilateral procedure, report the bilateral code with modifier 52 appended. In this instance, modifiers LT or RT may be reported in another modifier position on the same claim line to describe which side the reduced procedure was performed on.
Q: Does one individual CPT or HCPCS code ever have more than one NPFS bilateral status indicator designation?
A: Yes, on occasion a code may have a global, professional, and technical component. The NPFS bilateral status indicator may vary between the components. When this occurs and one of the status indicators is bilateral eligible (e.g. NPFS bilateral indicator "1" or "3") and another is not bilateral eligible (e.g. NPFS bilateral indicator "0", "2" or "9"), the code is added to the UnitedHealthcare Bilateral Eligible Procedures Policy List.
Q: What is the most appropriate way for a physician or other health care professional to bill UnitedHealthcare for a Bilateral Procedure?
A: The procedure should be billed on one line with a modifier 50 and one unit with the full charge for both procedures.
Q: What is the most appropriate way for a physician or other health care professional to report to UnitedHealthcare for hand or foot codes that are on the UnitedHealthcare Bilateral Eligible Procedures Policy List, but the same procedure is performed bilaterally on only one digit of each hand or foot?
A: If the same procedure is performed on the same digit on each hand or foot, report the procedure with modifier 50. If the same procedure is performed on a different digit or multiple digits of each hand or foot, report the procedure with the appropriate digit modifiers (e.g. FA or F1-9 [fingers], TA or T1-9 [toes]).
Q: What is the most appropriate way for a physician or other health care professional to report to UnitedHealthcare for bilateral eligible spinal codes, such as a laminotomy, if the procedure is performed on multiple levels of the same spinal region?
A: If the laminotomy is performed bilaterally, report the appropriate code with modifier 50 for the first interspace. If a laminotomy of a second interspace is performed bilaterally, use add-on codes to represent additional levels rather than sides. If a laminotomy of additional interspaces (3 or more) is performed bilaterally, report the appropriate code with modifiers 50 and 59 or XS with the appropriate number of units.
Q: Does UnitedHealthcare accept modifier 50 on all codes where the CPT book indicates coding guidelines to report modifier 50 when performing the procedure bilaterally?
A: No. UnitedHealthcare follows the CMS NPFS Bilateral Procedures payment indicators "1" or "3" to determine which codes are eligible for bilateral services.
Q: Does UnitedHealthcare apply a reduction to Bilateral Procedures with a payment indicator of “1” if the Multiple Procedure Reduction indicator is “0”?
A: Yes. UnitedHealthcare applies a reduction to all Bilateral Procedures with a payment indicator of “1” when billed with a modifier 50 or on separate lines with modifiers LT and RT regardless of the Multiple Procedure Reduction indicator.