Outpatient Facility Coding Alert

Question: What are the differences between the bilateral surgery indicators?

Utah Subscriber

Answer: If you’re ever wondering whether to append a laterality modifier on a particular surgical or ancillary CPT^® code, you should check the code’s bilateral surgery indicator. The bilateral surgery indicator will reveal one of five options:

• 0 — The concept of “bilateral” does not apply. This typically means that, physiologically speaking, coding on a left and right side is not possible. Consider a surgical procedure on the heart, such as 33427 (Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring). A bilateral surgery indicator of “0” also applies to ancillary services, such as 71045 (Radiologic examination, chest; single view).
• 1 — Bilateral billing rules apply. When you see a bilateral surgery indicator of “1,” you may append the respective modifiers of LT (Left Side) and RT (Right Side) or 50 (Bilateral Procedure) when the physician performs the procedure bilaterally.
• 2 — The payment adjustment for bilateral procedures does not apply. You might be wondering how this indicator differs from a bilateral surgery indicator of “0.” When you see a code with bilateral surgery indicator “2,” the bilateral concept does not apply because the value of the code already factors the bilateral component into the equation. However, codes with a bilateral surgery indicator of “2” will be obvious when viewing the code description. You’ll typically see that the surgery or service is either “bilateral” or “unilateral or bilateral.” You will find plenty of these services within the Radiology chapter of the CPT^® manual. For instance, consider codes 73050 (Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction) and 77047 (Magnetic resonance imaging, breast, without contrast material; bilateral).
• 3 — While the other bilateral surgery indicators also include radiological services, bilateral surgery indicator “3” is exclusive to radiological services in which billing bilaterally is allowed, but the reimbursement differs from that of services with a bilateral surgery indicator of “1.” For services with a bilateral surgery indicator of “1” that are billed bilaterally, the first side is reimbursed at 100 percent of the fee schedule amount. However, the other side is reimbursed at 50 percent of the fee schedule amount. This is the case when you submit with modifiers LT and RT. If you submit with modifier 50, the reimbursement amount is the same, however the payer will reimburse for the single unit at 150 percent the fee schedule amount. The code description for these services will typically not include terminology indicating that it is a unilateral service. Instead, it will only indicate that it’s imaging of an anatomic site that has two distinct sides. Most typically, these services will include joint X-rays such as 73030 (Radiologic examination, shoulder; complete, minimum of 2 views).
• 9 — Bilateral concept does not apply. You’ll want to distinguish this indictor from that of bilateral surgery indicator “1.” While an indicator of “1” may be appended to surgical services where the bilateral concept doesn’t apply from a physiological perspective, an indicator of “9” is used for services that have no anatomic relevancy at all. For instance, consider moderate sedation code 99151 (Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports…).

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