Describe how to correctly code bilateral procedures using CPT.

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Bilateral procedures are those performed on both sides of the body (e.g., both knees, eyes, or arms). Correctly coding them using CPT ensures accurate billing and reimbursement. Here’s how to do it:

✅ 1. Check the CPT Code Descriptor

• Some CPT codes already include bilateral procedures (e.g., certain eye or ear codes).

• If so, do not add modifiers or extra units.

✅ 2. Use Modifier -50 (Bilateral Procedure)

• Apply -50 to indicate the procedure was performed on both sides.

• Do not bill two line items unless your payer (e.g., Medicare) requires it.

✅ 3. Use Units or Line Items (Payer-Specific)

Some payers want:

• One line with -50 and 1 unit

• Or two lines:

• (Each with modifier -RT or -LT and 1 unit)

✅ 4. Do Not Use -50 with Add-on Codes

• Add-on codes (e.g., +69990) are never reported with -50.

• They only apply per side, if appropriate.

✅ 5. Use Modifier -RT and -LT When Appropriate

• If modifier -50 isn’t accepted, use -RT (right) and -LT (left) on separate lines.

✅ 6. Review Payer Policies

• Medicare and commercial payers may have different rules.

• Always check their specific billing guidelines.

Correct use ensures compliance, fewer denials, and proper payment.

Read More

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