Bilateral Procedures: Exceptions to the 150 Percent Payment Adjustment

This article is from July/August 2004 and may contain outdated material.

When you perform a procedure on both eyes, you typically expect to be paid 100 percent of the allowable for the first eye and 50 percent for the second. However, not all codes are typical. This 150 percent payment adjustment does not apply when CPT codes have a bilateral indicator of zero.

So what happens if you report one of these atypical procedures with modifier –50 bilateral procedure or modifiers –LT left side and –RT right side? The payer will base payment for both eyes on either the total actual charge for both sides or 100 percent of the fee schedule amount for a single code, whichever amount is lower. For instance, suppose the fee schedule amount for code XXXXX is $125 and the physician reports code XXXXX–LT with an actual charge of $100 and XXXXX–RT with an actual charge of $100. Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).

CPT codes with a bilateral indicator of zero.
The following codes are atypical —in that the bilateral payment adjustment does not apply to them—because of 1) physiology or anatomy or 2) the code description specifically states that it is a unilater procedure and there is an existing code for the bilateral procedure.

• 67221 Photodynamic therapy (includes intravenous infusion)
• 67225 Photodynamic therapy, second eye, at single session (list separately in addition to code for primary eye treatment)
• 67800 Excision of chalazion; single
• 67801    multiple, same lid
• 67805    multiple,different lids
• 67808    under general anesthesia and/or requiring hospitalization, single or multiple
• 67810 Biopsy of eyelid
• 67820 Correction of trichiasis; epilation, by forceps only
• 67825    epilation by other than forceps (e.g., by electrosurgery, cryotherapy, laser surgery)
• 67830    incision of lid margin
• 67835    incision of lid margin, with free mucous membrane graft
• 67840 Excision of lesions of eyelid (except chalazion) without closure or with simple direct closure
• 67850 Destruction of lesion of lid margin (up to 1 centimeter)
• 67875 Temporary closure of eyelids by suture (e.g., Frost suture)
• 67880 Construction of intermarginal adhesions, median tarsorrhaphy or canthorrhaphy;
• 67882    with transposition of tarsal plate
• 67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
• 67930 Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; partial thickness
• 67935    full thickness
• 67938 Removal of embedded foreign body, eyelid
• 67950 Canthoplasty (reconstruction of canthus)
• 67961 Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin
• 67966    over one-fourth of lid margin
• 67971 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid, up to two-thirds of eyelid, one stage or first stage
• 67973    total eyelid, lower, one stage or first stage
• 67974    total eyelid, upper, one stage or first stage
• 67975    second stage
• 68020 Incision of conjunctiva, drainage of cyst
• 68040 Expression of conjunctival follicles (e.g., for trachoma)
• 68100 Biopsy of conjunctiva
• 68110 Excision of lesion, conjunctiva, up to 1 cm
• 68115    over 1 cm
• 68130    with adjacent sclera
• 68135 Destruction of lesion, conjunctiva
• 68320 Conjunctivoplasty; with conjunctival graft or extensive rearrangement
• 68325    with buccal mucous membrane graft (includes obtaining graft)
• 68326 Conjunctivoplasty, reconstruction cul-de-sac; with conjunctival graft or extensive rearrangement
• 68328    with buccal mucous membrane graft (includes obtaining graft)
• 68330 Repair of symblepharon; conjunctivoplasty, without graft
• 68335    with free graft conjunctiva or buccal mucous membrane (includes obtaining graft)
• 68340    division of symblepharon, with or without insertion of conformer or contact lens
• 68360 Conjunctival flap; bridge or partial (separate procedure)
• 68362    total (such as Gunderson thin flap or purse string flap)
• 68371 Harvesting conjunctival allograft, living donor
• 68400 Incision, drainage of lacrimal gland
• 68420 Incision, drainage of lacrimal sac (dacryocystotomy or dacryocystostomy)
• 68440 Snip incision of lacrimal punctum
• 68500 Excision of lacrimal gland (dacryoadenectomy), except for tumor; total
• 68505    partial
• 68510 Biopsy of lacrimal gland
• 68520 Excision of lacrimal sac (dacryocystectomy)
• 68525 Biopsy of lacrimal sac
• 68530 Removal of foreign body or dacryolith, lacrimal passages
• 68540 Excision of lacrimal gland tumor; frontal approach
• 68550   involving osteotomy
• 68700 Plastic repair of canaliculi
• 68705 Correction of everted punctum, cautery
• 68720 Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity)
• 68745 Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube
• 68750    with insertion of tube or stent
• 68770 Closure of lacrimal fistula (separate procedure)
• 68840 Probing of lacrimal canaliculi, with or without irrigation
• 68850 Injection of contrast medium for dacryocystography