CurrentPremera BluecrossPolicy cmi_051749

Site-specifying modifiers (eyelid/finger/toe) and laterality billing rules

Defines when Premera recognizes site-specifying HCPCS/CPT modifiers appended to professional procedure claims and laterality rules that affect reimbursement; applies to Premera and affiliated product lines and provider types submitting professional claims.

Policy Summary

PayerPremera Bluecross

PolicySite-specifying modifiers (eyelid/finger/toe) and laterality billing rules

Policy CodePolicy cmi_051749

Change TypeClarification and additions (laterality guidance, modifier listings, single-modifier rule)

Effective Date

Next Review Date

Key ActionVerify member eligibility, benefit limits, and applicable medical policy before submitting professional claims with site-specifying modifiers.

SourceLink

POLICY UPDATE CHANGES

Provided clarification on the correct usage of Modifiers LT and RT in the 'Policy' section.

Listed the Eyelid, Finger, and Toe individual modifiers.

Added a paragraph indicating only one site-specifying modifier should be appended to a procedure code.

In the Laterality section, added criteria to bill bilateral surgical procedures and guidance on selecting diagnosis codes when bilateral diagnosis codes exist.

3site groups listed (eyelid, finger, toe)

1site-specifying modifier allowed per procedure code

LT/RT vs 50laterality guidance

Multiplelines of business covered

Site-specifying modifier and laterality rules

Site-specifying modifier and laterality criteria

Coverage and reimbursement rules for site-specifying and laterality modifiers when billed on professional claims:

Coverage of any service is determined by member eligibility, benefit limits, and application of the Plan's Medical Policy; final payment is subject to claims adjudication edits.

The Plan recognizes HCPCS/CPT site-specifying modifiers appended to professional procedure codes to indicate procedures performed at specific anatomical sites (examples include eyelid, finger, and toe modifiers).

Only one site-specifying modifier should be appended to an applicable procedure code; examples include 67800 - E1 (upper left eyelid) and 67800 - E2 (lower left eyelid).

Laterality: LT or RT on the procedure code must match laterality on the ICD-10-CM diagnosis code; conflicts between diagnosis laterality and procedure laterality will result in non-reimbursement.

Policy Summary

PayerPremera Bluecross

PolicySite-specifying modifiers (eyelid/finger/toe) and laterality billing rules

Policy CodePolicy cmi_051749

Change TypeClarification and additions (laterality guidance, modifier listings, single-modifier rule)

Effective Date

Next Review Date

Key ActionVerify member eligibility, benefit limits, and applicable medical policy before submitting professional claims with site-specifying modifiers.

SourceLink

On This Page

Billing and verification requirements

Billing Rule

Pre-claim verification and modifier submission — Ensure member eligibility, benefit limits, and applicable medical policy are verified; submit site-specifying modifiers on professional claims as instructed

Verify member eligibility, benefit limits, and applicable medical policy before submitting claims. Final payment is subject to claims adjudication edits and the Plan's professional or facility coding policies. Reimbursement is restricted to the provider of record. Submit site‑specifying modifiers on professional claims as instructed to indicate procedures performed on the same patient at specific anatomical sites.

Pre-claim verification: confirm member eligibility, benefit limits, and that the service meets the Plan's medical policy prior to claim submission.
Modifier submission: append site‑specifying modifiers to the appropriate procedure code on professional claims to denote the anatomical site(s) where the procedure was performed.
Claims processing: final payment is subject to standard adjudication edits and applicable coding policies; incorrect or missing modifiers may affect reimbursement.

Modifier definitions and laterality terms

inv-05: Site-specifying modifier

DefinitionModifier appended to a procedure code indicating the specific anatomical site (e.g., eyelid, finger, toe) on which the procedure was performed.

Recognized site groupsEyelid, finger, and toe site-specifying modifiers are recognized by the Plan (HCPCS/CPT site modifiers).

Billing positionModifiers that affect reimbursement should be billed first; site-specifying modifiers should be billed in subsequent modifier positions.

VerificationCoverage and payment are subject to member eligibility, benefit limits, Plan medical policy, and claims adjudication edits.

inv-06: Laterality modifiers (LT/RT) vs Bilateral modifier (50)

LT/RT usageModifiers LT and RT indicate a procedure performed on one anatomic side and should be used when a procedure is performed on only one anatomic side; they must match ICD-10-CM diagnosis laterality.

Modifier 50 (Bilateral)Modifier 50 represents a bilateral procedure when performed on identical anatomic locations and should be used instead of LT/RT to indicate bilateral surgery.

Eyelids/fingers/toes guidanceProcedures on eyelids, fingers, or toes should use the appropriate site-specific modifiers rather than LT/RT unless the procedure is not related to those sites.

Diagnosis coding when bilateralIf no bilateral ICD-10-CM diagnosis code exists and the condition is bilateral, assign separate left and right diagnosis codes.

Reimbursement impactConflicts between procedure code laterality and diagnosis code laterality will result in non-reimbursement; second/subsequent procedures may be subject to bilateral or multiple procedure reductions.

E1	Upper left eyelid
E2	Lower left eyelid
E3	Upper right eyelid
E4	Lower right eyelid
F1	Left hand, second digit
F2	Left hand, third digit
F3	Left hand, fourth digit
F4	Left hand, fifth digit
F5	Right hand, thumb
F6	Right hand, second digit

OpenPayer

Site-specifying modifiers (eyelid/finger/toe) and laterality billing rules

Site-specifying modifier and laterality rules

Allowed modifiers and coding limits

Billing and verification requirements

Modifier definitions and laterality terms