Understanding Payment Indicators

Understanding how payment works with Medicare payment indicators and the impact a modifier has on payment is vital to pricing. Even if you are not billing Medicare, most carriers follow Medicare's policies for participating and non-participating rules.  Here is an article from Regence on their policy statement, describing the rules they follow. These are the same rules CMS has in place as well as most other payers.  If you are using Find-A-Code, the status indicators are located on each code information page under “Additional Information”.  Not every modifier has an indicator or status, but some of the modifiers that impact payment will be listed, for example:

Multiple Procedures (51):

The Multiple procedures indicator allows for the use of Modifier 51 stating this modifier is allowed and can be used with the code if this indicator is present. Modifier 51 is defined as multiple surgeries/procedures.  

CPT Modifier 51 may be used for

• additional procedure/same session
• same procedure/multiple times
• same procedure/different site

One example of how payment rules apply is the use of Modifier 51 indicator #2

2- Standard payment adjustment rules for multiple procedures apply. If a procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50% and by report). Base the payment on the lower of:

(a) the actual charge, or

(b) the fee schedule amount reduced by the appropriate percentage.

       NOTE: Certain codes, including all add-on codes, are Modifier 51 exempt.    

Bilateral Surgery (50)

CPT Modifier 50 is defined as a modifier used to report procedures that are performed during the same operative session, on the same day, on both sides of the body.

       NOTE: Ambulatory Surgery Centers (ASCs) are an exception and cannot submit CPT Modifier 50 and will continue to use the unit’s field to reflect bilateral services.

Indicator 0 – Do not submit these procedures with CPT Modifier 50. The concept of “bilateral” does not apply. These do not meet the bilateral criteria.

150% payment adjustment for bilateral procedures does not apply. If a procedure is reported with Modifier -50 or with modifiers RT and LT, base the payment for the two sides on the lower of:

(a) the total actual charge for both sides or

(b) 100% of the fee schedule amount for a single code. Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).

The bilateral adjustment is inappropriate for certain codes:

(a) because of physiology or anatomy, or

(b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

C) the procedure is not commonly performed as a bilateral procedure.

Examples: 71020, 93010, 97124

27369 does not meet the criteria for a bilateral procedure (see the Indicator -0-) on the additional code information page on Find-A-Code.  Therefore, you need to bill 1 line item with 2 units or two separate line items, one line with a RT and one line with a LT modifier, this may depend on what your payer requires.

Indicator 1 – Submit the procedure on a single detail line with CPT Modifier 50 and a quantity of 1.

Valid for bilateral billing - bilateral claim submission criteria apply. Payment is adjusted for bilateral procedures if codes are submitted with CPT Modifier 50. Payment is based on the lower of the billed amount or 150% of the Medicare fee schedule allowed amount.

Examples: CPT codes 66984, 27447

Indicator 2 - Do not submit these procedures with CPT Modifier 50. These codes are already established as being performed bilaterally.

Examples: CPT code/HCPCS modifier 76519-TC, global procedure CPT code 76519, CPT code 93970

Indicator 3 - Submit the procedure on a single detail line with CPT Modifier 50 and a quantity of 1.

Radiological Procedures valid for bilateral criteria are radiology/diagnostic tests that are not subject to the special payment rules for other bilateral surgeries, and payment for each side is based on 100% of the fee schedule amount.

Example: CPT code/modifier 76519-26

Indicator 9 - Do not submit these procedures with CPT Modifier 50; bilateral concept does not apply.

Global Days

Global Days are postoperative care for either zero (0), ten (10), or ninety (90) days.

APC Status indicator

Example Q2- T-Packaged Codes

OPPS Payment Status:

Paid under OPPS; Addendum B displays APC assignments when services are separately payable.

1. Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator "T."
2. In all other circumstances, payment is made through a separate APC payment.

Indicator N - Items and Services Packaged into APC Rates

Reference & Resources

Regence Policy Statement - Non-Participating Providers: https://www.regence.com/web/regence_provider/reimbursement-methodology-for-non-participating-providers

CMS Medicare Claims Processing Manual (Pub.100-04), Chapter 23, in the “Addendum – MPFSB Record Layout” (see Field 22):http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf 

Payment for Multiple Procedures to ASCs: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 14, section 40.5: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf

CGS – Bilateral Surgeries: https://www.cgsmedicare.com/pdf/bilateral_job_aid.pdf

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