Payment calculation of Bilateral procedure with Example

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

Calculate payment using all payment modifiers associated with the line item.

Example 1:Modifiers 50, AS (physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) and 80 (assistant surgeon) are submitted on the line. The line item HCPCS/CPT code is authorized for both bilateral surgery and assistant at surgery. Payment would be made based on the lesser of the actual charges or the following calculation: (facility specific MPFS amount times bilateral procedure adjustment (150 percent) times assistant at surgery reduction (16 percent) times non-physician practitioner adjustment (85 percent) minus (deductible and coinsurance)) times 115 percent.

Example 2:Modifiers 50 and 62 (two surgeons) are submitted on the line. The line item HCPCS/CPT code is authorized for both bilateral surgery and co-surgery. Payment would be made based on the lesser of the actual charges or the following calculation: (facility specific MPFS amount times bilateral procedure adjustment (150 percent) times co-surgery reduction (62.5 percent) minus (deductible and coinsurance)) times 115 percent.

Note: Medicare contractors will not search for and adjust claims that have been paid prior to the implementation date of CR 6526, but will adjust claims brought to their attention.

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