CurrentColorado Rocky Mountain Health PlansPolicy 2026R0023B

Bilateral procedure coding and reimbursement for CMS 1500 claims

Defines UnitedHealthcare's reimbursement rules for reporting and paying bilateral procedures on CMS-1500 forms (and applicable UB04 when specified) for Commercial and Individual Exchange plans, and for all network and non-network physicians and Other Qualified Health Care Professionals.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBilateral procedure coding and reimbursement for CMS 1500 claims

Policy CodePolicy 2026R0023B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionReport bilateral procedures by adding modifier 50 on one line with one unit and the full charge for both procedures when the code is on the Bilateral Eligible Procedures Policy List.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

150%reimbursement for bilateral indicator '1' codes

200%reimbursement potential for bilateral indicator '3' codes

applies to all productsapplies to UnitedHealthcare Commercial and Individual Exchange plans

CMS 1 or 3NPFS bilateral status indicators

CMS 1500

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Bilateral Procedure Reimbursement Criteria

Bilateral procedure reimbursement criteria

Covered when ALL of the following conditions are met:

ALL of the following

ALL of the following
- Code must be on UnitedHealthcare's Bilateral Eligible Procedures Policy List (codes in CMS NPFS with bilateral indicator '1' or '3').
Reporting methods accepted
- ALL of the following
  - When a true bilateral procedure is performed at the same session, report the procedure on one line with modifier 50 and one unit and the full charge for both procedures; this is reimbursable only if the code is on the Bilateral Eligible Procedures Policy List.
- OR
  - Report on separate lines with modifiers LT and RT for the same structure; UnitedHealthcare will apply CMS payment methodology to bilateral eligible procedures reported with LT/RT as described below.
ALL of the following
- If NPFS bilateral indicator = '1': Apply CMS payment methodology: reimburse at 150% of the single allowable amount (one side at 100% and the other at 50%) not to exceed billed charges; additional multiple procedure/MPPR reductions may or may not be applied to the line paid at 100% depending on ranking of other reducible procedure codes.
- If NPFS bilateral indicator = '3': If not subject to Multiple Procedure or MPPR reductions, reimburse 100% of the allowable for each side (sum 200% of the allowable) not to exceed billed charges.
ALL of the following
- Codes with 'bilateral' or 'unilateral or bilateral' in the CPT/HCPCS description are not on the Bilateral Eligible Procedures Policy List and must not be reported with modifier 50; when such codes are reported with LT/RT, only one charge may be eligible for reimbursement up to the Maximum Frequency Per Day value.
- If only a bilateral code exists but the procedure was performed unilaterally, report the bilateral code with modifier 52 for reduced service per CPT guidance and UnitedHealthcare Reduced Services Policy; LT/RT may be used informatively.
- In rare instances where bilateral services are performed on multiple distinct sites beyond simple bilateral (e.g., multiple digits), use modifier 59 (or XS) to report additional distinct-site services with supporting documentation.

Coding Rules and Payment Adjustments

Bilateral eligible per NPFS indicatorsmixed

1	NPFS bilateral indicator '1' — codes with this indicator are considered eligible for bilateral reporting methods; reimbursed at 150% of single allowable (one side 100%, other 50%) when reported bilaterally.
3	NPFS bilateral indicator '3' — codes with this indicator are considered eligible for bilateral reporting methods; eligible for reimbursement at 100% of allowable for each side (sum 200%) when reported bilaterally and not subject to MP/MPPR reductions.

Codes inherently bilateral or unilateral/bilateralmixedNot Covered

bilateral	CPT/HCPCS codes with 'bilateral' in the description are inherently bilateral; when reported with LT/RT only one charge may be eligible up to Maximum Frequency Per Day limits and modifier 50 is not allowed as these codes are not on the Bilateral Eligible Procedures Policy List.
unilateral or bilateral	CPT/HCPCS codes with 'unilateral or bilateral' in the description are inherently able to represent either side; when performed unilaterally modifier 52 is not required and LT/RT are informational only; reporting LT/RT separately by the same individual results in only one eligible charge up to MFD limits.

inv-04: payment_adjustment_indicator_1

Payment adjustmentReimbursed at 150% of the single allowable when NPFS bilateral indicator = '1' (one side paid at 100% and the other at 50%), not to exceed billed charges; CMS payment methodology applied even if Multiple Procedure Indicator present.

Billing formatReport with modifier 50 on one line and one unit with the full charge for both procedures when code is on UnitedHealthcare's Bilateral Eligible Procedures Policy List.

Alternative reportingCan be reported on separate lines with LT and RT modifiers for the same structure; payment adjustment methodology for indicator '1' still applies.

inv-05: payment_adjustment_indicator_3

Payment adjustmentEligible for reimbursement at 100% of the allowable amount for each side (sum 200% of the allowable) when NPFS bilateral indicator = '3', not to exceed billed charges, provided not subject to MP/MPPR reductions.

Billing and Modifier Guidance for Providers

Billing Rule

Billing bilateral procedures with modifier 50

Billing bilateral procedures with modifier 50 — report bilateral procedures performed at the same session by adding modifier 50 on one line with one unit and the full charge for both procedures. A procedure code submitted with modifier 50 is reimbursable only when it appears on the payer's Bilateral Eligible Procedures list. If the code is not on that list, it will not be reimbursed. When bilateral services are performed on multiple distinct sites, consider modifier 59 (or XS) to report additional units; medical record documentation must support use of modifier 59/XS.

Denial Risk

Prohibited use of modifier 50 and LT/RT on inherently bilateral codes

Prohibited use of modifier 50 and LT/RT on inherently bilateral codes — CPT/HCPCS codes that include the term "bilateral" or "unilateral or bilateral" in the description are not eligible for reimbursement with modifier 50. When such codes are reported, LT/RT modifiers may be accepted only as informational; when both LT and RT are reported separately by the same provider on the same day for an inherently bilateral code, only one charge will be eligible for reimbursement up to the Maximum Frequency Per Day (MFD) limit.

Key Definitions

inv-09: The same procedure performed on both sides of the body during the same session. — definition: Bilateral Procedures

DefinitionThe same procedure performed on both sides of the body during the same session.

ApplicationUsed to determine when bilateral reporting methods (modifier 50 or LT/RT) and payment adjustments apply, per policy.

DistinctionCodes that explicitly include 'bilateral' in the description are considered inclusive and have special reporting rules (not reported with modifier 50).

inv-10: The same individual rendering services reporting the same Federal Tax Identification number. — definition: Same Individual Physician or Other Qualified Health Care Professional

DefinitionThe same individual rendering services reporting the same Federal Tax Identification number.

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