CurrentUnitedHealthcarePolicy N/A

Bilateral procedure billing and reimbursement

Defines billing and payment rules for procedures performed bilaterally, including use of modifier 50, LT/RT, units, and state exceptions; applies to Community Plan Medicaid providers submitting CMS1500/UB04 claims.

Policy Summary

PayerUnitedHealthcare

PolicyBilateral procedure billing and reimbursement

Policy CodePolicy N/A

Change TypeState exceptions addedattachments updated

Effective DateN/A

Next Review DateN/A

Key ActionReport bilateral procedures on one line with modifier 50 and one unit when the code is on the Bilateral Eligible Procedures Policy List.

SourceLink

POLICY UPDATE CHANGES

North Carolina state exception was added and an NC Eligible Codes List was added to attachments.

Policy attachments updated multiple times including Bilateral Eligible Procedures and lists of codes with 'bilateral' or 'unilateral or bilateral' in the description.

Idaho state exception was added.

CMS1500/UB04Claim form applicability

Indicators 1 & 3NPFS bilateral eligible indicators

150%Reimbursement for indicator '1'

200%Reimbursement for indicator '3'

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CO, ID, MO, NC, DC, WIStates with exceptions

Bilateral Procedure Coverage Criteria

Bilateral procedure coverage criteria

Payment and reporting criteria for bilateral procedures.

Codes with NPFS bilateral indicator '1' or '3' are eligible for bilateral reporting when included on the UnitedHealthcare Community Plan Bilateral Eligible Procedures Policy List.

Payment adjustments by NPFS indicator

For NPFS bilateral indicator '1', apply CMS payment adjustment methodology: reimburse at 150% of the allowable amount for a single procedure (one side reimbursed at 100% and the other at 50%), not to exceed billed charges. Additional multiple procedure or MPPR reductions may be applied to the line paid at 100% depending on ranking.
For NPFS bilateral indicator '3', when the code is not subject to Multiple Procedure or MPPR reductions, reimburse each side at 100% of the allowable amount for a total of 200% of the allowable amount, not to exceed billed charges.

When a bilateral-eligible procedure is performed at the same session, report the procedure on one claim line with modifier 50 and one unit and the full charge for both procedures; a code submitted with modifier 50 is reimbursable only if it is listed on the Bilateral Eligible Procedures Policy List. Codes submitted with modifier 50 that are not on the list will not be reimbursed.

Do not append modifier 50 to CPT or HCPCS codes that already include 'bilateral' or 'unilateral or bilateral' in the code description; when only a bilateral-described code exists but the service is performed unilaterally and no unilateral code exists, report the code with modifier 52 per CPT guidelines and the Reduced Services Policy.

When both LT and RT modifiers are reported for codes that are inherently bilateral or include 'bilateral' in the description, only one charge will be eligible for reimbursement up to the Maximum Frequency Per Day limits; LT/RT may be informational only for codes stating 'unilateral or bilateral.'

In rare instances where bilateral services are performed on multiple sites, use modifier 59 (or XS) to report additional units beyond the bilateral service and ensure medical record documentation supports the different site or organ system claim.

State-specific exceptions apply: Colorado reimburses codes with bilateral indicator '1' or '3' at 180% of the allowable amount; Idaho prices a secondary procedure billed with modifier 50 at the billed amount or 75% of Medicaid's allowed amount, whichever is less; Missouri and Washington, DC reimburse per their fee schedules; North Carolina maintains its own eligible code list for modifier 50; Wisconsin reimburses modifier 50 per its fee schedule.

Policy applies to services billed on CMS1500 or UB04 claim forms or their electronic equivalents for UnitedHealthcare Community Plan Medicaid products.

Coding, Modifiers, and Reimbursement

Bilateral eligibility by NPFS indicatormixedCovered

NPFS indicator 1	CMS bilateral eligible indicator 1 — eligible for 150% payment methodology
NPFS indicator 3	CMS bilateral eligible indicator 3 — eligible for 200% payment when not subject to reductions

Reimbursement cap

Reimbursement capNot to exceed billed charges

Applied to NPFS indicator 1 and 3 paymentsPayment adjustments (150% for indicator '1', 200% for indicator '3' when not reduced) shall not exceed billed charges

Interaction with multiple procedure reductionsWhen other reducible procedure codes are reported the 100% line may be subject to additional multiple procedure/MPPR reductions

Colorado multiplier (state exception)

Colorado state exceptionCodes with a NPFS bilateral indicator of '1' or '3' are reimbursed at 180% of the allowable amount in Colorado

Other state exceptions listed

Billing and Provider Requirements

Billing Rule

Bilateral modifier 50 billing requirements

Report bilateral procedures performed in the same session by appending modifier 50 to the appropriate CPT or HCPCS code and billing the procedure on one line with modifier 50 and one unit reflecting the full charge for both procedures. Only codes listed on the UnitedHealthcare Community Plan Bilateral Eligible Procedures Policy List are reimbursable when submitted with modifier 50; codes not on that list will not be reimbursed with modifier 50.

Bill the procedure on one line with modifier 50 and one unit representing both sides.
Ensure the code is on the UnitedHealthcare Community Plan Bilateral Eligible Procedures Policy List; otherwise modifier 50 submissions will not be reimbursed.
For services performed on different sites/organs, consider modifier 59 with supporting medical record documentation.

Billing Rule

Handling codes with 'bilateral' in description

Definitions

Same Individual Physician or Other Qualified Health Care Professional

DefinitionThe Same Individual Physician or Other Qualified Health Care Professional is the same individual rendering health care services reporting the same Federal Tax Identification number

Relevance to billingIf services are performed and reported under the same Federal Tax Identification Number, they are considered performed by the Same Individual for bilateral billing rules

Applies toCPT/HCPCS codes on the Bilateral Eligible Procedures Policy List billed with modifier 50 or LT/RT

Bilateral Procedure

DefinitionA Bilateral Procedure is the same procedure performed on both sides of the body during the same session

Billing with modifier 50

Policy Summary

PayerUnitedHealthcare

PolicyBilateral procedure billing and reimbursement

Policy CodePolicy N/A

Change TypeState exceptions addedattachments updated

Effective DateN/A

Next Review DateN/A

Key ActionReport bilateral procedures on one line with modifier 50 and one unit when the code is on the Bilateral Eligible Procedures Policy List.

SourceLink

On This Page

Idaho, Missouri, North Carolina, Washington DC, and Wisconsin have separate pricing or fee-schedule rules (see policy for details)

ScopeApplies only to services subject to UnitedHealthcare Community Plan bilateral policy in Colorado

Do not append modifier 50 to CPT/HCPCS codes that already include 'bilateral' or 'unilateral or bilateral' in their description. If a bilateral-described code is performed unilaterally and no unilateral code exists, report the bilateral code with modifier 52; when both LT and RT are reported for inherently bilateral codes, only one charge will be eligible for reimbursement up to the Maximum Frequency Per Day value.

Codes with 'bilateral' or 'unilateral or bilateral' in the description are not on the Bilateral Eligible Procedures Policy List and will not be reimbursed with modifier 50.
When a unilateral code does not exist, append modifier 52 to the bilateral-described code if performed unilaterally.
LT/RT modifiers on inherently bilateral codes are informational only; when both LT and RT are reported by the Same Individual, only one charge may be reimbursed up to MFD limits.

Documentation Required

Same Individual definition

For bilateral billing purposes, when the same individual performs services and reports the same Federal Tax Identification Number, they are considered the Same Individual Physician or Other Qualified Health Care Professional.

When LT and RT are reported separately on the same day by the Same Individual, only one charge will be eligible for reimbursement up to the maximum frequency per day limit (consistent with CMS guidelines).

Bilaterally eligible codes on the policy list should be billed on one line with modifier 50 and one unit, or on separate lines with LT and RT modifiers for the same structure

Codes with 'bilateral' in descriptionCPT/HCPCS codes that include 'bilateral' in their description are inclusive of the bilateral procedure and should not be reported with modifier 50 or LT/RT