0164-Bilateral Indicator '3': Incorrect Coding

Submitted by Matthew.Gregor… on Mon, 11/04/2019 - 07:48
Issue Number - Name
0164-Bilateral Indicator '3': Incorrect Coding
Review Type
Automated
Date Approved
2019-09-10

Description

A Bilateral Indicator of "3" indicates the usual payment adjustment for bilateral procedures does not apply.  If the procedure is reported with either a modifier 50 or modifiers RT and LT, and a ‘2’ in the units field, reimbursement is based on 100% of the Medicare allowed amount for each side less any applicable multiple procedure pricing rules. This query identifies claims with underpayments due to code being submitted with a quantity of "2” when performed bilaterally.

Affected Codes

Bilateral Indicator ‘3’ codes

Applicable References

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4. 42 CFR §405.986- Good Cause for Reopening
5. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests
6. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements – Addendum - MPFSDB Record Layouts, File Layout through 2018
7. Medicare Claims Processing Manual, Chapter 12- Physician/ Non-Physician Practitioners, §40.7 – Claims for Bilateral Surgeries