Medicare payment - Bilateral procedures - Critical Access Hospital

Payment of Bilateral Procedures in a Method II Critical Access Hospital (CAH)

In summary, Medicare contractors will:

  • Return to Provider (RTP) bilateral procedures submitted on TOB 85X with RC 96X, 97X or 98X when the HCPCS/CPT code billed with the 50 modifier, has a payment policy indicator of ‘0’, ‘2’, or ‘9’.
  • Payment Policy Indicator 0 – 150 percent payment adjustment for bilateral procedures does not apply. The bilateral procedure is inappropriate for codes in this category because of physiology or anatomy or the code descriptor specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.



  • Payment Policy Indicator 2 - 150 percent payment adjustment for bilateral procedures does not apply. The relative value units (RVUs) are based on a bilateral procedure because the code descriptor states that the procedure is bilateral, the codes descriptor states that the procedure may be performed either unilaterally or bilaterally, or the procedure is usually performed as a bilateral procedure.



  • Payment Policy Indicator 9 - concept does not apply.






  • RTP bilateral procedures submitted on TOB 85X with RC 96X, 97X or 98X when the bilateral procedure code is billed with the RT and LT modifiers and the payment policy indicator is ‘1’ or ‘3’. This includes claims with a bilateral procedure and modifiers LT and RT on the same claim line or claims with the same bilateral procedure on two claim lines with the same line item date of service (LIDOS), one claim line with modifier RT and another claim line with modifier LT.
  • Payment Policy Indicator 1 – 150 percent payment adjustment for bilateral procedures does apply.



  • Payment Policy Indicator 3 - 150 percent payment adjustment for bilateral procedures does not apply. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral procedures.






  • Pay for bilateral procedures on TOB 85X with RC 96X, 97X or 98X, one service unit and modifier 50 when the HCPCS/CPT code has a payment policy indicator of ‘1’ based on the lesser of the actual charges or the 150 percent payment adjustment for bilateral procedures as follows: (facility specific MPFS amount times bilateral procedure adjustment (150 percent) minus (deductible and coinsurance)) times 115 percent.



  • Pay for bilateral procedures on TOB 85X with RC 96X, 97X or 98X and modifier 50 and one service unit when the HCPCS/CPT code has a payment policy indicator of ‘3’ based on the lesser of the actual charges or 200 percent of the MPFS amount as follows: (facility specific MPFS amount times 200 percent (100 percent for each side) minus (deductible and coinsurance)) times 115 percent. NOTE: Although the 150 percent payment adjustment does not apply to payment policy indicator ‘3’, modifier 50 may be billed with these procedures. When billed with the 50 modifier, payment is based on the lower of the actual charges or 200 percent of the MPFS amount.
     



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