According to chapter 1, section V(3) of the
2017 CCI manual, “edits based on established CMS policies may limit units of service. For example, the bilateral surgery indicator on the Medicare Physician Fee Schedule Database (MPFSDB) may limit reporting of bilateral procedures to a single unit of service reported.” The 2018 manual expands on that statement by adding detailed information for each bilateral surgery indicator:
- 0 (150% payment adjustment for bilateral procedures does not apply) – A bilateral procedure would be reported with one unit of service. “There is no additional payment for the code if reported as a unilateral or bilateral procedure because of anatomy or physiology,” the manual states. Trigger point injections (20552-20553) and diagnostic laryngoscopy (31575) are examples of codes with a bilateral surgical indicator of 0.
- 1 (150% payment adjustment for bilateral procedures applies) – Bilateral surgical procedures such as treatment of rib fractures (21812-21813) and femoral blocks (64447) are reported with one unit of service and modifier 50 (Bilateral procedure). Bilateral diagnostic procedures such as renal biopsy (50200-50205) and needle biopsy of lymph nodes (38505) may be reported as follows:
- Two units of service on one claim line.
- One unit of service and modifier 50 on one claim line.
- One unit of service with modifier RT (Right side) one claim line and one unit of service with modifier LT (Left side) on a second line.
- 2 (150% payment adjustment does not apply) – A bilateral procedure is reported with one unit of service. According to new language in the chapter, procedures such as initial and subsequent control of nose bleed (30905-30905), ear wax removal that requires instrumentation (69210) and eye exams (92002-92014) are priced as bilateral because based on the code descriptor or the fact that the procedure is usually performed bilaterally.
- 3 (The usual payment adjustment for bilateral procedures does not apply) – The guidelines for services with a bilateral indicator of 1 apply to dozens of radiology services, including X-ray of the elbow (73070) and CT scan of lower extremities (73700-73702).
Next year’s manual also explains how a code’s descriptor influences the number of MUEs. When a descriptor includes the word unilateral, and there is a separate code for a bilateral procedure the procedure, the MUE for the unilateral procedure will be ‘1,’ the manual states. For example, the unilateral code for excision of hydrocele (55040) has an MUE of 1 because there is a separate code for the bilateral procedure (55041).