If you report bilateral procedures — and most practices do — how you tell your payers that you performed the same services on both sides of the body depends greatly on the payer itself. But there are some general tools and strategies you can follow that will point you in the right direction, and help you improve your overall reimbursement — regardless of the insurance carrier involved.

For most payers, you have three options for reporting bilateral procedures:

• Option 1 — Append modifier 50 (Bilateral procedure) to one instance of the procedure code (e.g., 20526-50).
• Option 2 — Report the same procedure code twice, and append modifier 50 to the second instance of the code (e.g., 20526, 20526-50).
• Option 3 — Report two instances of the procedure code, and use anatomic modifiers (RT [Right side], LT [Left side], E1-E4 [eyelids], FA-F9 [fingers], TA-T9 [toes]) to indicate the bilateral nature (e.g., 20526-RT, 20526-LT).

The option you choose to file your bilateral procedure claims will depend on your payers’ requirements. Choose the wrong option with the wrong carrier and you can count on being denied.

But how do you know if you can report a procedure as bilateral in the first place? There’s an easy tool that will give you the information you need — the Medicare Physician Fee Schedule (MPFS) — if you know how to use it.  Below is they key components of the MPFS are essential for you to master in order to accurately bill bilateral services.

In Column T of the MPFS Relative Value File (which you can download at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html), you’ll find the Bilateral Surgery Indicator for each procedure and service code. The number listed in Column T will tell you if you can report that procedure code as bilateral:

• 0 — The bilateral surgery rules do not apply to these codes because one of the following situations applies:
  • Physiology or anatomy (there is no bilateral body part).
  • Code description specifically states that it is a bilateral procedure.
  • Procedure is not normally performed bilaterally.
• 1 — The code is valid for bilateral coding. For Medicare, this means that it will reimburse the bilateral procedure at 150% of the allowable payment if you report the CPT® code with the appropriate modifier.
• 2 — You should not report this code with a bilateral modifier. Medicare has already valued these codes as bilateral procedures, which means the code meets one of the following criteria:
  • Descriptor specifically states that the procedure is bilateral.
  • Descriptor indicates that the physician may perform the procedure either unilaterally or bilaterally.
  • Procedure is usually performed bilaterally.
• 3 — You can report these codes bilaterally, but there is no payment adjustment for them. This generally means that you should receive 100% reimbursement for each side of the body rather than the 150% that Medicare usually pays for bilateral services. Because of this, many carriers prefer that you use the anatomical modifiers if you see this indicator in column T, which is normally reserved for radiological procedures and other diagnostic tests.
• 9 — The bilateral concept does not apply to these codes, therefore you cannot bill them with modifiers 50, LT, RT, etc.

For example, 43180 (Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus [e.g., Zenker’s diverticulum], with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair) has a 0 modifier indicator in column T, so you can’t bill this code bilaterally. This makes perfect sense because the anatomy in this case is not bilateral — you have only one esophagus.

On the other hand, 20526 (Injection, therapeutic [e.g., local anesthetic, corticosteroid], carpal tunnel) has a 1 modifier indicator. So if your physician injects the carpal tunnels in both wrists, you can report that bilaterally, using the option that your payer prefers (most likely with modifier 50).

And 73020 (Radiologic examination, shoulder; 1 view) has a 3 indicator in column T. In this case, if your provider performs this service on both the right and left sides, you would likely report it as 73020-RT and 73020-LT.

The MPFS is an underutilized and essential coding resource. And it’s the only true way of knowing when you can report procedures bilaterally.  It can save you time and money by avoiding denials and ensuring your payments are timely and accurate.

Take Aways:

• Use the MPFS to know when — and frequently how — you can report procedures as bilateral.
• Look for modifier indicators 1 and 3 in column T because they mean you can bill the procedure bilaterally.
• Modifier indicators 0, 2 and 9 mean bilateral coding is not an option.