Single claims where a bilateral procedure is secondary to either another bilateral procedure, or any other higher valued procedure, and the provider is an ASC.
An understanding from reading both the CPT, CMS manuals and AMA Coding with Modifiers, is that the first bilateral procedure is allowed 150% of billed. In the case of an ASC, they each side on separate lines, using RT, LT instead of modifier 50. This is born out by received claims. The reimbursement is then 100% of the allowable for the first line and 50% for the second line. No problem there. That easily applies to a bilateral procedure be it the only procedure on the claim or if it is the primary procedure on a claim with other procedures that are eligible for a multiple procedure reduction. In either case, we would only apply the bilateral logic.
The issue comes when the provider bills multiple bilateral procedures on a single claim in which case shouldn't the reimbursement expected by (assuming all codes are multiple surgery eligible) - ooly on procedures subsequent to the primary (be it single or bilateral) – first you apply a bilateral reimbursement and then the multiple procedure reduction?
An understanding from reading both the CPT, CMS manuals and AMA Coding with Modifiers, is that the first bilateral procedure is allowed 150% of billed. In the case of an ASC, they each side on separate lines, using RT, LT instead of modifier 50. This is born out by received claims. The reimbursement is then 100% of the allowable for the first line and 50% for the second line. No problem there. That easily applies to a bilateral procedure be it the only procedure on the claim or if it is the primary procedure on a claim with other procedures that are eligible for a multiple procedure reduction. In either case, we would only apply the bilateral logic.
The issue comes when the provider bills multiple bilateral procedures on a single claim in which case shouldn't the reimbursement expected by (assuming all codes are multiple surgery eligible) - ooly on procedures subsequent to the primary (be it single or bilateral) – first you apply a bilateral reimbursement and then the multiple procedure reduction?