What is Modifier 50 in Medical Billing?

Did you know that most practices nationwide experience 4-20% denied claims? During the AAPC’s REVCON, i.e., a virtual boutique conference, it was made clear that skipping modifiers is one of the top reasons behind these denials. The host emphasized that everyone pays the cost when denials occur.

But how? On average, it costs $25 for practices to rework claims. That’s not all, it costs payers anywhere from $100 to $400 per claim, going from start to finish.

This guide? It is dedicated to discussing modifier 50. Once you are done, you will know where it applies and when to avoid using it. So, continue reading!

Modifier 50 – Description

Modifier 50 indicates that the physician performed the procedure on both sides of the patient’s body. In other words, the procedure was performed bilaterally. Additionally, it is a pricing modifier that results in a 150% payment adjustment for the reported procedural code.

Modifier 50 – Usage Examples

Let’s review a few clinical scenarios where this modifier applies:

Bilateral Knee Injections for Osteoarthritis

Picture a 67-year-old male patient with chronic grade III osteoarthritis in both knees. On his follow-up visit, he complains that physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) are no longer helping him manage the pain.

Thus, the physician performs an arthrocentesis and injects 20 mg of Kenalog into the left intra-articular space (knee joint cavity). He then repeats the same procedure on the right intra-articular space.

Here, you must append modifier 50 to CPT code 20610 to indicate bilateral services.

Bilateral Carpal Tunnel Release

Assume a 46-year-old female dental hygienist comes to the clinic. She complains about experiencing severe numbness and “pins and needles” in the thumb, index, and middle fingers of both hands.

Electromyography (EMG) findings confirm bilateral carpal tunnel syndrome. Thus, the surgeon performs an open carpal tunnel release on the right wrist. The surgical team immediately repositions the patient and performs a matching open release on the left wrist.

You must report CPT code 64721 with modifier 50 to ensure a 150% payment adjustment.

Bilateral Sinus Debridement

Imagine a 35-year-old male patient who comes to the clinic for a two-week follow-up after functional endoscopic sinus surgery (FESS).

The physician identifies crusting and obstructive debris in both the left and right nasal cavities using a nasal endoscope. Therefore, he performs a thorough suction debridement and tissue removal on the right side, followed by the left side.

Here, you must append modifier 50 to CPT code 31237 to highlight bilateral services.

Accurate Usage Guidelines for Modifier 50

The following are the usage guidelines that will help you ensure a clean claim submission every time:

Understand When You Should Use Modifier 50

Discussed below are the key criteria to ensure the appropriate use of this modifier:

• You can only use it for procedures that can be performed on paired organs or extremities. These include legs, arms, ovaries, kidneys, breasts, eyes, ears, and nostrils.
• The bilateral service must happen during the same clinical or operative encounter by the same healthcare practitioner.
• Report it for procedural codes that have a ‘1’ in the Bilateral Indicator column of the Medicare Physician Fee Schedule (MPFS).

Know When NOT to Use Modifier 50

You can prevent the misuse of this modifier by understanding when not to use it:

• In case the CPT code description already states the service to be unilateral or bilateral (e.g., 52290), avoid using it.
• You cannot append it to procedures on singular midline organs like the bladder, uterus, or esophagus.
• If the CPT code has an indicator of ‘0’, modifier 50 does not apply. A zero indicator means the physiology of the procedure does not allow for a bilateral application.
• Procedural codes with ‘2’ indicator mean the relative value units (RVUs) already assume a bilateral procedure is performed.
• Do not use this modifier on skin lesion services because skin lesions are reported by the number of lesions or total area.

Fulfill Documentation Requirements

Your supporting documentation must support the use of modifier 50 to prevent denials and audits. Here’s what it must include:

• The operative note or encounter summary that clearly describes the work performed on each side.
• An explanation for why the procedure was required on both sides, e.g., imaging confirms bilateral stenosis.
• A mention of specific details for both sides, such as the volume of medication injected, the size of the incision, or the specific findings for each anatomical structure.
• A justification for the additional time and professional effort required to perform the procedure twice.

Final Thoughts on Modifier 50

With that said, it is time to conclude this guide. Hopefully, after reading this guide, you will have clarity on when or when not to use modifier 50.

Just remember a few things! First, it represents that you rendered bilateral services. Second, the indicator on MPFS should be 1. Finally, you cannot use it for procedures that treat singular midline organs, like the bladder, uterus, or esophagus.

Not sure if you can handle the coding and billing requirements yourself? Consider acquiring medical billing and coding services from professionals like NeuraBill.

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