Bilateral Total Knees—How to Submit the Claim From

Question:

How do I report bilateral procedures, one line or two?

Answer:

Great question, unfortunately the payors have made this simple concept of bilateral procedures challenging from a reimbursement standpoint! Survey your payors and obtain their individual instruction in writing. Even Medicare varies from Contractor to Contractor For Medicare, check your Carrier Manual or website for their instructions.

The questions to ask are:

1) Does the payor want bilateral procedures reported on one line (linear format)?

2) Does the payor want bilateral procedures reported on two lines (line item reporting)?

3) Does the payor want you to use right and left modifiers instead of the modifier 50?

If the payor prefers the linear format, then the following questions need answers:

A) Do you report one unit or two?

B) Do you submit your fee one time or double?

Example of linear reporting format:

CPT® code/modifier Charge Units

27447-50, place a 1 or 1 in the units box based on payor instructions and submit the fees at one or two times your normal fee. KZA recommends doubling the fee when reporting on one line.

If the payor prefers line item reporting, append modifier 50 to the second CPT® procedure code that is the bilateral procedure .

Example of line item reporting format:

CPT® code/modifier Charge Units

27447 Submit a 1 in the units box and submit your full fee

27447-50 Submit a 1 in the units box and submit your full fee

In either scenario, watch your reimbursement closely to ensure the payor reimburses 100% for the first procedure and 50% for the second or according to the payors multiple procedure payment formula.