Modifier 50 and 51: Multiple and Bilateral Surgery
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Defines Amerigroup's reimbursement rules for multiple and bilateral surgical procedures, including how modifiers 50 and 51 should be applied for professional and facility claims and applicable payment reductions; applies to providers billing Amerigroup (Georgia programs listed).
No material clinical or coverage changes in this revision.
Multiple and Bilateral Surgery Reimbursement Rules
Multiple and bilateral surgery payment and billing rules
Reimbursement allowed for multiple and bilateral surgeries subject to the following payment reductions and modifier usage:
ALL of the following
- Pay 100% of the fee schedule or contracted/negotiated rate for the highest‑valued procedure.
- Pay 50% for the secondary through fifth procedures.
- Pay 50% for the sixth and additional procedures only if determined to be medically necessary through clinical review.
ALL of the following
- Pay 100% of the fee schedule or contracted/negotiated rate for the highest‑valued procedure.
- Pay 50% for the secondary through fifth procedures.
- Pay 25% for the sixth and additional procedures only if determined to be medically necessary through clinical review.
ALL of the following
- Professional provider claims for applicable surgical procedures must be billed with modifier 51 to denote additional procedures.
- Facility claims should not be billed with modifier 51.
- Long‑acting reversible contraception (LARC) procedures are excluded from multiple surgical reduction.
ALL of the following
- When a bilateral surgery uses a unilateral code, report on a single line with modifier 50 for professional and facility claims.
- Reimbursement is 150% of the fee schedule or contracted/negotiated rate when billed with modifier 50.
ANY of the following
- Do not append modifiers LT, RT, or 50.
- Reimbursement is 100% of the fee schedule or contracted/negotiated rate.
ALL of the following
- Claims billed without the correct modifier to denote multiple or bilateral procedures may not be eligible for reimbursement.
Modifiers and Bilateral Reporting
| 50 | Modifier 50: Bilateral Procedure |
| 51 | Modifier 51: Multiple Procedures |
| LT | Modifier LT: Left side |
| RT | Modifier RT: Right side |
Key Definitions
Authorization, Medical Necessity, and Billing Requirements
Authorization, medical necessity, and documentation requirements
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence. Use proper billing and submission guidelines (CPT, HCPCS, revenue codes) and ensure all billed services are fully supported in the medical record and/or office notes; failure to follow coding/billing guidelines or policy may result in claim rejection, denial, recovery/recoupment, or adjustment of reimbursement.
- Obtain any required prior authorization per the member's benefit plan and state requirements before performing the procedure.
- Document the procedure, diagnosis, and medical necessity thoroughly in the medical record or office notes to support the CPT/HCPCS/revenue codes billed.
- Follow industry-standard coding and submission rules; lack of appropriate coding or documentation may trigger claim denial, recovery, or payment adjustment.
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