CurrentHumanaPolicy CP2007013

Modifier 50 billing and reimbursement

Defines Humana's billing requirements and payment adjustments for procedures reported with modifier 50 for Medicare Advantage and Commercial products; applies to professional services and affects providers submitting claims to Humana.

Policy Summary

PayerHumana

PolicyModifier 50 billing and reimbursement

Policy CodePolicy CP2007013

Change TypeNo material change

Effective DateDec 1, 2007

Next Review Date

Key ActionSubmit modifier 50 on a single claim line with unit=1 for bilateral procedures or provide documentation for reconsideration of additional units.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

150%Bilateral Payment Adjustment

Units = 1Single claim line processing

RVF=1Bilateral indicator condition

MSR may applyMultiple surgery reduction

Modifier 50 Billing and Payment Criteria

Modifier 50 billing and payment criteria

Billing and reimbursement criteria for bilateral procedures reported with modifier 50.

ALL of the following

Use modifier 50 when a procedure is performed bilaterally on similar sites on opposite sides of the body during the same session by the same qualified health care practitioner.
When a service code has an MPFS RVF bilateral indicator 1 and the procedure is performed bilaterally, providers must report the code with either modifier 50 or with anatomical modifiers (LT and RT). Humana encourages modifier 50 but accepts both methods (single claim line unit=1 for modifier 50; two claim lines each unit=1 when using LT and RT).Units = 1
Only report modifier 50 for procedures performed on similar but opposite sites (e.g., right and left knee). Do not report modifier 50 for procedures on different anatomic sites (e.g., right knee and left shoulder).

Policy Summary

PayerHumana

PolicyModifier 50 billing and reimbursement

Policy CodePolicy CP2007013

Change TypeNo material change

Effective DateDec 1, 2007

Next Review Date

Key ActionSubmit modifier 50 on a single claim line with unit=1 for bilateral procedures or provide documentation for reconsideration of additional units.

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.

ALL of the following

When reporting two or more bilateral procedures using the same code, report the first bilateral procedure on a single claim line with unit=1 using modifier 50.
Report subsequent bilateral procedures on a single claim line with unit=1 using modifier 50 and modifier 59.

ALL of the following

Modifier 50 may be reported in addition to eyelid, finger and toe modifiers on one claim line with unit=1 for procedures performed bilaterally on similar but opposite sites (examples: E1 and E3 with 50 for upper left and upper right eyelid; F2 and F7 with 50 for left and right third digit; TA and T5 with 50 for left and right great toe).
Do not use modifier 50 when paired anatomical sites are not similar/opposite (examples: E1 and E4; F2 and F8; TA and T7); bill as two claim lines each unit=1 with appropriate anatomical modifiers.

ALL of the following

Humana applies BPA only to service codes with an MPFS RVF bilateral indicator 1.
When BPA applies, the allowed amount for a bilaterally performed procedure is the lesser of the total charged for both sides or 150 percent of either the provider's contracted unilateral rate that would have applied if done unilaterally or the base maximum amount payable under the member's plan for an out-of-network provider.

ALL of the following

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.

ALL of the following

When a bilateral procedure is reported with another procedure on the same date of service, a multiple procedure payment reduction may be applied after the bilateral payment adjustment.
The procedure with the highest allowed amount after BPA is paid at 100%; other procedures are reduced per MSR rules (example: second procedure allowed at 50% of 150% of base amount).

Applicable Modifiers and Claim Units

Modifiers referencedModifier

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

Claim line units when using modifier 50

Claim line units when using modifier 50Report a single claim line with a unit of 1 when using modifier 50 for a bilateral procedure; providers may submit supporting documentation for reconsideration of additional units.

Alternative reporting with LT/RTIf reporting with anatomical modifiers LT and RT, submit two claim lines, each with a unit of 1.

Multiple bilateral procedures same codeWhen reporting two or more bilateral procedures using the same code, report the first on a single claim line unit=1 with modifier 50; subsequent bilateral procedures on a single claim line unit=1 with modifier 50 plus modifier 59.

Plan and Provider Requirements

Documentation Required

Comply with plan medical necessity, reasonableness, and referral/authorization rules

Claims payments are subject to other plan requirements for processing and payment of claims, including requirements of medical necessity and reasonableness and applicable referral or authorization requirements. These plan-level requirements apply in addition to this modifier 50 policy and to professional services only.

Terms and Reference Files

Base maximum amount payable under the member's plan

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

Role in bilateral payment adjustmentUsed as the base maximum amount for calculating the allowed amount for out-of-network providers when applying the bilateral payment adjustment.

Actual reimbursementActual plan reimbursement may be less than this base maximum because of applicable adjustments.

Medicare Physician Fee Schedule (MPFS) Relative Value File (RVF)

SourceA file published by the Centers for Medicare & Medicaid Services (CMS) that includes bilateral indicator, relative value units (RVUs) and conversion factors for physician services.

Bilateral indicator useHumana applies the bilateral payment adjustment only to service codes with an MPFS RVF bilateral indicator 1.

ContainsIncludes information used to determine whether a service code is designated as bilateral for payment rules.

Modifier 50

DefinitionBilateral procedure.

When to reportReport modifier 50 when a procedure is performed on similar sites on opposite sides of the body; Humana encourages modifier 50 but accepts LT/RT reporting as an alternative.

Claim line instructionWhen using modifier 50, report a single claim line with unit=1.

Modifier 59

DefinitionDistinct procedural service.

Interaction with modifier 50Modifier 59 may be used with modifier 50 for subsequent bilateral procedures when multiple bilateral procedures using the same code are reported.

PurposeIndicates a service or procedure that is separate and distinct from other services performed on the same day.

Modifier LT

DefinitionLeft side (used to identify procedures performed on the left side of the body).

Alternative to modifier 50Humana accepts reporting bilateral procedures using LT and RT modifiers as two claim lines each with unit=1, though modifier 50 is encouraged.

Use caseUse LT to identify unilateral procedures performed on the left side when not reporting modifier 50.

Modifier RT

DefinitionRight side (used to identify procedures performed on the right side of the body).

Alternative to modifier 50Humana accepts reporting bilateral procedures using LT and RT modifiers as two claim lines each with unit=1, though modifier 50 is encouraged.

Use caseUse RT to identify unilateral procedures performed on the right side when not reporting modifier 50.