CurrentColorado Rocky Mountain Health PlansPolicy 2026R9009A

Bilateral Procedure Reimbursement

Defines billing and payment adjustment rules for bilateral surgical procedures for UnitedHealthcare Medicare Advantage plans and applies to services billed on the CMS 1500 form by network physicians and other qualified health care professionals.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBilateral Procedure Reimbursement

Policy CodePolicy 2026R9009A

Change TypeNon‑material administrative updates

Effective Date

Next Review Date

Key ActionWhen NPFS bilateral indicator = 1, apply a 150% payment adjustment or bill with modifier 50 as appropriate.

SourceLink

POLICY UPDATE CHANGES

Resources section updated on 6/1/2024 and policy version anniversaries noted for 6/1/2024, 6/1/2025 and 6/1/2026.

150%payment adjustment applied when bilateral indicator = 1

100%base payment when bilateral payment rules do not apply

CMS 1500claim form applicability

ASC exceptionASC exception

Bilateral Procedure Payment Rules

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Bilateral Procedure Payment Criteria

Billing and payment adjustment rules for bilateral procedures:

If a procedure can be billed bilaterally, bill the service with modifier 50; do not report modifier 50 if the CPT/HCPCS terminology already identifies the procedure as bilateral or unilateral or bilateral.

Do not report LT/RT when modifier 50 applies.

When NPFS bilateral indicator = 1, apply a 150% payment adjustment; payment is the lower of the total actual charge for both sides or 150% of the fee schedule amount for a single code.

When NPFS bilateral indicator = 0, 2, or 3, bilateral payment adjustment rules do not apply; base payment on the lower of billed amount or 100% of the fee schedule amount unless other payment adjustments apply.

When NPFS bilateral indicator = 9, the bilateral concept does not apply.

If a code's descriptor includes 'bilateral' and the procedure was performed bilaterally, do not append modifier 50; if the code is inherently bilateral but the procedure was performed unilaterally and a unilateral code exists, report the unilateral code; if no unilateral code exists, report the bilateral code with modifier 52.

When bilateral surgeries are billed with other procedures, treat the bilateral payment (150% for both sides) as one payment amount, rank it with remaining procedures, and apply the appropriate multiple surgery reduction as applicable.

Ambulatory Surgical Centers (CMS Specialty 49) are excluded from the modifier 50 requirement and should bill bilateral services on two lines using LT/RT per CMS/NCCI rules.

Modifiers, Code Sources, and Payment Multipliers

Relevant modifiers and code sourcesModifier

50	Bilateral procedure modifier
LT	Left side modifier
RT	Right side modifier
59	Distinct procedural service modifier

Code sourcesmixed

CPT	CPT Code Section
NPFS	National Physician Fee Schedule Relative Value Files
HCPCS	HCPCS Release & Code Sets

Bilateral payment multiplier

Bilateral payment multiplier150% when NPFS bilateral indicator = 1; payment is the lower of total actual charge for both sides or 150% of the fee schedule for a single code.

No bilateral adjustment when indicator = 0, 2, or 3Bilateral payment rules do not apply; base payment is the lower of billed amount or 100% of the fee schedule unless other adjustments apply.

Indicator 9When NPFS bilateral indicator = 9, the bilateral concept does not apply.

Key Definitions

Bilateral procedure (definition)

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

Billing implicationIf a code's descriptor includes 'bilateral' the 50 modifier should not be reported; use the unilateral code if available or report the bilateral code with modifier 52 when no unilateral code exists.

Multiple surgery treatmentWhen billed with other procedures, treat the bilateral 150% payment for both sides as one payment amount and apply appropriate multiple surgery reductions.

Same Individual Physician or Other Qualified Health Care Professional (definition)

DefinitionThe same individual rendering health care services reporting the same Federal Tax Identification number or NPI number.

Claim form applicabilityPolicy applies to services billed on the CMS 1500 form by network physicians and other qualified health care professionals.

Use in billing rulesDetermines when multiple lines or modifiers represent services by the same rendering individual for bilateral reporting and payment adjustments.