Updates to Billing for Bilateral Surgical Procedures.

Beginning Dec. 8, 2024, and for services provided on or after Jan. 1, 2020, new guidelines will apply to billing for bilateral surgical procedures with the bilateral RVU indicator of “1” for bilateral procedures (modifier 50). See the Centers for Medicare & Medicaid Services PFS Relative Value Files webpage.

*Reference Column T – BILAT SURG

Codes with the modifier 50 indicator of “1,” are valid for bilateral billing claim submission. With the exception of CPT codes inherently bilateral by definition, Medicaid requires practitioners to report procedures performed bilaterally, left and right, same procedure, same date of service, on one claim line with modifier 50 appended to the code (e.g., xxxxx-50, billed with 1 unit). Failure to report bilateral procedures in this way may result in incorrect processing or denial of claims.

Reporting these bilateral-indicator-1 procedures with either LT or RT and 1 unit of service is appropriate only if the procedure is being performed unilaterally. If the procedure is performed bilaterally, modifier 50 must be appended to the procedure code with 1 unit of service.

When a surgery is performed bilaterally, on the left and right, with the same procedure code and date of service, providers should submit a single claim line billed with the bilateral procedure modifier 50.

The following new edits and EOBs are being implemented to support these changes. 

EOB

Description

02259

CLAIM LINE DENIED. BILATERIAL MODIFER 50 MUST BE BILLED WHEN THE SAME SERVICE IS PERFORMED ON BOTH THE LEFT(LT) AND RIGHT(RT) ON THE SAME DAY

60900

CLAIM LINE DENIED. MODIFER LT OR RT IS NOT ALLOWED WHEN THE SAME SERVICE IS PAID IN HISTORY WITH BILATERIAL MODIFER 50 FOR THE SAME DATE OF SERVICE.

60910

CLAIM IS PAID. THE HISTORY CLAIM WILL BE REVERSED. MODIFER LT OR RT IS NOT ALLOWED WHEN THE SAME SERVICE IS PAID WITH BILATERIAL MODIFER 50.

60920

CLAIM LINE DENIED. MODIFER LT OR RT IS PAID IN HISTORY FOR SAME SERVICE ON SAME DATE. IF A BILATERAL PROCEDURE WAS PERFORMED, RESUBMIT WITH BILATERAL MODIFIER 50.