- Los Angeles
- San Diego
- San Joaquin
Bilateral procedures are procedures that are performed on both sides of the body at the same operative session or on the same date of service. Health Net's list of codes eligible for bilateral reimbursement is based on the Centers for Medicare and Medicaid Services (CMS) list. Health Net also follows CMS payment methodology wherein the allowable rate of reimbursement for bilateral procedures is either 150 percent of the rate that would be allowable if the procedures were only performed on one side of the body or 100 percent of the rate for each side.
To report bilateral procedures for codes that allow 150 percent payment for both sides, use modifier -50 (bilateral procedure) on appropriate codes in the surgical series (10021-69979) and the medicine series (90281-99602).
When billing for these bilateral procedures, the applicable procedure code should be reported on two separate lines, one with the base procedure code, and one with the procedure code and modifier -50.
To report bilateral procedures, for codes that allow 100 percent payment for each side, report the procedure code twice with modifier RT (right) on one line and modifier LT (left) on another line on appropriate codes in the radiology series (70010-79999), and appropriate codes in the medicine series (90281-99602).
Bilateral procedures fall into one of three categories:
- Procedures that may not be reported bilaterally (it is inappropriate to report the following types of procedures with modifier -50 or RT/LT):
- Procedures that are bilateral in nature
- Procedures that cannot be performed bilaterally based on anatomy
- Procedures on parts of the body that have multiple units on both sides (fingers and toes)
- Procedures specifying unilateral in the code description if there is an existing code for the bilateral procedure
- Procedures specifying bilateral in the code description
- Procedures specifying unilateral or bilateral in the code description
- Procedures paid at 150 percent of the allowed amount for both sides*
- Procedures paid at 100 percent of the allowed amount for each side*
* May be subject to reduction by the multiple procedure reduction rule.
Health Net does not require documentation at the time of claim submission; however, if the claim is audited, documentation may be required.
- CMS National Policy