CurrentHumanaPolicy CP2007013

Modifier 50 (bilateral procedure)

Billing and reimbursement rules Humana applies when providers report bilateral procedures using modifier 50 for Medicare Advantage and Commercial products; affects professional service claims for Humana members and participating/non‑participating providers.

Policy Summary

PayerHumana

PolicyModifier 50 (bilateral procedure)

Policy CodePolicy CP2007013

Change TypeNo material change

Effective DateDec 1, 2007

Next Review Date

Key ActionSubmit bilateral procedures using modifier 50 as a single claim line with unit=1 when performed on similar opposite sites; ensure codes have MPFS RVF bilateral indicator = 1 for bilateral payment adjustment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

150%maximum allowed payment for a bilaterally performed procedure (of base amount)

MPFS RVF = 1service codes eligible for Humana bilateral payment adjustment

1 unitsingle claim line unit when using modifier 50 for bilateral procedures

MSR may applymultiple surgery reduction may be applied after bilateral payment adjustment

Bilateral Billing and Payment Adjustment Criteria

Policy Summary

PayerHumana

PolicyModifier 50 (bilateral procedure)

Policy CodePolicy CP2007013

Change TypeNo material change

Effective DateDec 1, 2007

Next Review Date

SourceLink

On This Page

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Bilateral billing and reimbursement criteria

When and how Humana applies bilateral billing and payment adjustments:

Only report modifier 50 when the procedure is performed on similar but opposite sites (for example, right and left knee); do not report modifier 50 for dissimilar sites (for example, right knee and left shoulder).

Billing options

Report a bilateral procedure using a single claim line with modifier 50 and a unit of 1 (Humana strongly encourages this method).
Or report bilateral procedures as two claim lines using anatomical modifiers LT and RT, each with a unit of 1 (Humana accepts this method).

When reporting two or more bilateral procedures using the same code: report the first bilateral procedure as a single claim line (modifier 50, unit=1) and report subsequent bilateral procedures as single claim lines using modifier 50 plus modifier 59 (each unit=1).

Report modifier 50 in addition to specified eyelid, finger and toe anatomical modifiers on one claim line with unit=1 when those procedures are performed bilaterally on similar opposite sites (examples: E1+E3 for upper left and upper right eyelids; F2+F7 for left and right third digits; TA+T5 for left and right great toes).

It is not necessary to report modifier 50 with service codes that have an MPFS RVF bilateral indicator other than 1.

Humana applies a bilateral payment adjustment (BPA) only to service codes with an MPFS RVF bilateral indicator = 1.

When BPA applies, the amount allowed for a bilaterally performed procedure is the lesser of: the total charged for both sides; or 150 percent of the unilateral base amount (the provider's contracted unilateral rate or the base maximum amount payable under the member's plan).

A single claim line with an MPFS RVF bilateral indicator 1 code billed with modifier 50 is processed as one unit; providers may submit supporting documentation for reconsideration of additional units.

When a bilaterally performed procedure is reported with another procedure on the same date of service, a multiple surgery reduction (MSR) may be applied after the bilateral payment adjustment. The highest‑ranked procedure after BPA is paid at 100%; other procedures are reduced (example: other procedures may be reduced by 50% per Humana's MSR rules).

Relevant Modifiers and Indicators

Modifiers discussedModifier

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

Bilateral indicator required for BPA

Bilateral indicator required for BPAMPFS RVF bilateral indicator = 1

Applies only to codes with indicator 1Humana applies bilateral payment adjustment only to service codes with MPFS RVF bilateral indicator 1.

Reporting requirement when using modifier 50When a procedure with MPFS RVF indicator 1 is performed bilaterally, providers must report the code with modifier 50 (single claim line, unit=1) or with LT/RT (two lines, each unit=1).

Plan Requirements and Authorization

Prior Authorization

Confirm plan authorization, medical necessity, and referral compliance

Claims payments are subject to plan requirements including medical necessity, reasonableness, and applicable referral or authorization requirements; ensure services meet those requirements before billing. This policy applies to professional services only and payment may be withheld or denied if plan authorization/referral rules or medical necessity are not met.

Verify member’s plan authorization/referral requirements and obtain any required prior authorization before providing the service.
Document medical necessity and reasonableness in the medical record to support the claim.
Submit claims consistent with the provider’s contracted terms and applicable plan rules to avoid payment denials.

Key Terms and Reference Files

MPFS RVF — definition

DefinitionThe Medicare Physician Fee Schedule (MPFS) Relative Value File (RVF) is a CMS file that includes bilateral indicator, relative value units and conversion factors for physician services.

PurposeUsed to identify codes eligible for Humana's bilateral payment adjustment based on the bilateral indicator.

Connection to billingHumana references the MPFS RVF bilateral indicator when determining whether to apply bilateral payment adjustments.

Base maximum amount payable under the member's plan — definition

Base maximum amount payable — definitionThe maximum amount of reimbursement for a covered expense, determined by the member's plan; may be the maximum allowable fee, the appropriate Medicare fee schedule rate, or an amount from another payment model.

Role in bilateral payment calculation150 percent of the base maximum amount (or contracted rate) is one comparator when calculating the allowed amount for a bilaterally performed procedure.

Actual reimbursement noteActual plan reimbursement may be less than the base maximum amount because of applicable adjustments.

Modifier 50 — definition

Modifier 50 — meaningModifier 50 denotes a bilateral procedure.

Billing with modifier 50When reporting a bilateral procedure with modifier 50, report a single claim line with a unit of 1.

When to useOnly report modifier 50 when the procedure is performed on similar but opposite sites (e.g., right and left knee); do not use for non‑opposite sites (e.g., right knee and left shoulder).