For Providers

Reimbursement Policies & Guidelines

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Modifiers 50 and LT/RT

Effective Date: May 10, 2016

Purpose:
To implement a multiple surgery reduction reimbursement structure in accordance to CMS guidelines and NJ regulations which can aid in future cost avoidance.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Scope:
All products are included, except

  • Products where Horizon NJ Health is secondary to Medicare (e.g. Medigap).
  • COB

Definitions:

Policy:
Bilateral surgical procedures that are identified by the presence of the “50” modifier or of the same code on separate lines reported once with the modifier “LT” and once with a modifier “RT” the rules for adjustment are to pay 150% of the fee schedule amount.

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association.  In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure: Bilateral procedures are identified by the presence of the “50” modifier or of the same code on separate lines reported once with the modifier “LT” and once with a modifier “RT”. For these codes the standard rules for adjustment is to pay 150% of the fee schedule amount.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.