CurrentAnthemPolicy G-06010

Multiple and Bilateral Surgery Reimbursement

Defines Anthem Blue Cross Medicare Advantage reimbursement rules for multiple and bilateral surgical procedures for professional and facility claims, including modifier usage and payment reductions.

Policy Summary

PayerAnthem

PolicyMultiple and Bilateral Surgery Reimbursement

Policy CodePolicy G-06010

Change TypeReview — no material changes

Effective DateDec 18, 2025

Next Review Date

Key ActionServices must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

SourceLink

POLICY UPDATE CHANGES

12/18/2025 - Review approved and effective: no changes

08/28/2023 - Review approved and effective: updated policy title to include Modifiers 50 and 51, and removed Professional and Facility Reimbursement

100%highest-valued procedure

50%2nd–5th procedures

50% (6th+)6th+ procedures

150%bilateral w/ modifier 50

Modifier 51professional claims

Multiple and Bilateral Surgery Coverage Rules

Coverage criteria for multiple and bilateral surgeries

Reimbursement rules for multiple and bilateral surgical procedures and expectations for modifier use and medical necessity.

Policy allows reimbursement for multiple and bilateral surgical procedures unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Payment for multiple procedures

100% of the fee schedule or the contracted/negotiated rate for the highest-valued procedure.
50% for the secondary through the fifth procedures.
50% for the sixth and additional procedures only if determined to be medically necessary through clinical review.

Modifier requirements for multiple procedures

Policy Summary

PayerAnthem

PolicyMultiple and Bilateral Surgery Reimbursement

Policy CodePolicy G-06010

Change TypeReview — no material changes

Effective DateDec 18, 2025

Next Review Date

Key ActionServices must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Modifiers and Payment Reductions

Modifiers for multiple and bilateral surgeryModifier

50	Modifier 50 — Bilateral Procedure (use on single line for bilateral when code is unilateral)
51	Modifier 51 — Multiple Procedures (append to additional procedures on professional claims)
LT	Modifier LT — Left side
RT	Modifier RT — Right side

Covered/Not Applicable Codesmixed

No codes listed

Multiple procedure payment reductions

Highest-valued procedure100% of the fee schedule or the contracted/negotiated rate

Second through fifth procedures50% of the fee schedule/contracted rate

Sixth and additional procedures50% only if determined medically necessary through clinical review

Key Terms and Modifiers

Bilateral

DefinitionBilateral procedures are performed on both sides of the body during the same operative session.

ReportingWhen a unilateral code is used for bilateral surgery, report on a single line with modifier 50 unless otherwise identified in the listings.

ScopeApplies to procedures performed on both sides during the same operative session.

Modifier 50

PurposeModifier 50 identifies bilateral procedures performed at the same session.

Usage instructionAdd modifier 50 to the appropriate 5-digit code when bilateral procedures are performed at the same session, unless otherwise identified in the listings.

Add-on codesDo not append modifier 50 to designated 'add-on' codes.

Modifier 51

PurposeModifier 51 identifies additional procedures performed at the same session by the same individual.

Professional claimsAppend modifier 51 to additional procedure codes on professional provider claims to denote multiple procedures.

Add-on codesDo not append modifier 51 to designated 'add-on' codes.

Multiple Surgeries

DefinitionDistinct surgical procedures performed by a provider on the same patient during the same operative session.

Multiple unitsA single surgical procedure submitted with multiple units may be subject to multiple procedure reduction guidelines.

Claim billingProfessional claims for applicable surgical procedures must be billed with modifier 51; facility claims should not use modifier 51.

Unilateral

DefinitionUnilateral procedures are procedures performed on one side of the body.

Contrast with bilateralIf the same procedure is performed on both sides, it is considered bilateral and reported accordingly.

Modifier guidanceDo not use modifier 50 on inherently bilateral codes; use LT/RT when appropriate for side-specific reporting on unilateral procedures.

Authorization, Medical Necessity, and Billing Actions

Documentation Required

Authorization and medical necessity required for reimbursement

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member's state of residence. Claims must use industry-standard, compliant codes (CPT, HCPCS, revenue codes) and those billed services must be fully supported in the medical record and/or office notes. Failure to follow appropriate coding/billing guidelines or reimbursement policies may result in claim rejection/denial, recovery/recoupment of payment, or adjustment of reimbursement.

Obtain any required prior authorization and document medical necessity in the medical record.
Bill with correct CPT/HCPCS/revenue codes and ensure the record supports the billed services.
Be aware that noncompliance may lead to claim denial, payment recovery, or adjustment.

Policy Revision Notes

2025-12-18reviewLatest

Review approved and effective; no changes to policy content noted.

2023-08-28title_update

Review approved and effective; policy title updated to include Modifiers 50 and 51 and Professional and Facility Reimbursement removed.

2020-11-25content_update

Review approved and effective; policy language updated for CMS alignment regarding same day or same session and Definition and Reference Material sections updated.

2018-12-21template_update

Review approved; policy template updated.

2018-02-23content_update

Review approved (effective 2020-03-01); same day language added, same session language removed, and multiple units policy language added.

2016-10-03payment_standard_update

Review approved and effective; multiple surgery reimbursement standard updated and 'unilateral or bilateral' language corrected.

2015-01-01initial_approval

Initial approval and effective date for the policy.