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Chapter 4.5. Division of Workers' Compensation
SUBCHAPTER 1. ADMINISTRATIVE DIRECTOR -ADMINISTRATIVE RULES
Article 5.3. Official Medical Fee Schedule
§9789.16.6. Surgery - Bilateral Surgeries.
(a) Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day.
The terminology for some procedure codes includes the terms “bilateral” (e.g., code 27395; Lengthening of the hamstring tendon; multiple, bilateral) or “unilateral or bilateral” (e.g., code 52290; cystourethroscopy; with ureteral meatotomy, unilateral or bilateral). The payment adjustment rules for bilateral surgeries do not apply to procedures identified by CPT as “bilateral” or “unilateral or bilateral” since the fee schedule reflects any additional work required for bilateral surgeries. The Bilateral Surgery (“Bilat Surg”) column of the National Physician Fee Schedule Relative Value File indicates whether the bilateral payment adjustment rules apply to a surgical procedure.
(b) Billing Instructions for Bilateral Surgeries
(1) If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral), report the procedure with modifier “-50.” (NOTE: This differs from the CPT coding guidelines which indicate that bilateral procedures should be billed as two line items.)
If a procedure is identified by the terminology as bilateral (or unilateral or bilateral), as in codes 27395 and 52290, do not report the procedure with modifier “-50”.
(A) If the Bilateral Surgery column of the National Physician Fee Schedule Relative Value File contains an indicator of “0,” “2,” or “3,” the payment adjustment rules for bilateral surgeries do not apply. Payment is determined by the lower of the billed amount or 100 percent of the fee schedule amount unless other payment adjustment rules apply.
NOTE: Some codes which have a bilateral indicator of “0” in the Bilateral Surgery column may be performed more than once on a given day. These are services that would never be considered bilateral and thus should not be billed with modifier “-50.” Where such a code is billed on multiple line items or with more than 1 in the units field and the claims administrator has determined that the code may be reported more than once, bypass the “0” bilateral indicator and refer to the multiple surgery field for pricing.
(B) If Bilateral Surgery column of the National Physician Fee Schedule Relative Value File contains an indicator of “1,” the standard payment adjustment for bilateral procedures apply. Payment is determined by the lower of the billed amount or 150 percent of the fee schedule amount. (Multiply the payment amount for the surgery by 150 percent.)
(c) The global surgery rules are applicable to bilateral procedures.
Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.
1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).
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