Description
A Bilateral Indicator of "3" indicates the usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with either a modifier 50 or modifiers RT and LT, and a ‘2’ in the units field, reimbursement is based on 100% of the Medicare allowed amount for each side less any applicable multiple procedure pricing rules. This query identifies claims with underpayments due to code being submitted with a quantity of "2” when performed bilaterally.
Affected Code(s)
Bilateral Indicator ‘3’ codes
Applicable References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Medicare Claims Processing Manual, Chapter 12- Physician/Nonphysician Practitioners, §40.7- Claims for Bilateral Surgeries C.3
9. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §50.6 Physician Fee Schedule Payment Policy Indicator File Record Layout – Bilateral Surgery Indicator (Modifier 50) 3
10. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements – Addendum – Medicare Physician Fee Schedule Database (PFSDB) Record Layouts and Field Descriptions
11. Physician Fee Schedule | CMS
12. Physician Fee Schedule Relative Value Files- PFS Relative Value Files | CMS
13. AMA CPT Codebook