How do you determine if a CPT code is Unilateral or Bilateral?

April 24, 2019

Becoming a medical biller and coder is a great option for an organized professional. There are a lot of numbers and facts involved that make it the perfect job for a detail-oriented person. These codes and procedures become a lot more simple when you understand what they mean. For instance, a CPT is also known as current procedural terminology. A CPT is a medical code set that is used to report medical, surgical, and diagnostic procedures and services. These reports are used by physicians, health insurance companies and accreditation organizations. They help to make sure that all records are correct and that patients are being accurately billed.

Medical Billing and Coding online program online college Tulsa Oklahoma

What does bilateral or unilateral mean in coding?

In medical billing and coding, each code has bilateral surgery indicators. These indicators will tell you if the code is bilateral or unilateral and how to expect the claim to process. This is an important concept to understand in this field. In this blog, we will cover what these terms mean for a medical biller and coder. In addition, we will cover a few tips to help you better understand these indicators.

Bilateral Code- Both Sides
Unilateral Code- One Side

You can tell if a code is bilateral or unilateral by looking up the code on your Medicare Administrative Contractor’s (MAC) website. For instance, you can look up what a certain procedure’s bilateral indicator is. For the state of Oklahoma, our current MAC is Novitas Solutions. Once on the site, you will access the physician fee schedule and enter your code. This allows you to obtain information on status indicators. A bilateral indicator is a number. Below is a description of what each one means.

Code Indicators:

Medical Billing and Coding online program online college Tulsa Oklahoma

What does 0 mean?

If the code has an indicator of zero it is a unilateral code. Which means it will be paid per eye or site. In general, you can expect difficulties in getting paid if it is done the wrong way. If the code is assigned an indicator of 0, the procedure should in general not be performed bilaterally. You can expect difficulties in getting paid if it is performed bilaterally. Use of modifier 50 would be inappropriate in most cases.

What does 1 mean?

If the code has an indicator of 1, it can be done bilaterally. These are billed on one line with modifier 50 and 1 unit. The 1 code indicates that one service was rendered to the right and left side at the same encounter. Claims will be processed at 150% of the allowable.
Most eye procedures have an indicator of 1.


What does 2 mean?

If the code has an indicator of two, it is a bilateral procedure code. You would not need to add a modifier 50 because the code is already bilateral. A code with this indicator lets the insurance company know that both sides were done. Claims will be processed at 100% of the allowable.


What does 3 mean?

If the code has an indicator of three, it can be done bilaterally but you will need to use a 50 modifier. The usual payment adjustment does not apply. Codes with an indicator of 3 are mostly radiology codes. Claims will be processed to pay 100% of the allowable for each side. For the total procedure, this is 200%.


What does 9 mean?

If the code has an indicator of nine, the concept does not apply. Codes that have this indicator are generally codes that are not specific to a certain side of the body. For example, general anesthesia would have an indicator of 9.

Tips For Medical Billing and Coding

Medical Billing and Coding online program online college Tulsa Oklahoma

I would highly suggest looking up most commonly used codes on your MAC’s site. This can be crucial because in ophthalmology, for example, some codes are paid per site, per lid, or per eye. It is important to know which one is which so that it is coded properly. For example, lash removal is coded per eye, not per the number of lashes removed. Medicare would not expect to see this code billed with multiple units. Overall, repeatedly billing out wrongful claims to Medicare or other insurances can cause a lot of problems.

Above all, medical billing and coding is a very detail oriented job. For instance, being organized is important to perform well in this role. You will be trained to read patient charts as a medical biller and coder. You will then process patient data such as patient diagnoses, treatment records, and health insurance information. After you process the information, you will manage requests for payment. These are from patients or the patient’s insurance company. Because this is such an important job, not everyone can do it. A qualified medical biller and coder is educated, organized and ready to work. Overall, medical billing and coding will take diligence and dedication.

Learn more about the MBC program! In addition, if you are interested in our other programs you can learn more here.

From the desk of Melissa Allen, CMC and Medical Billing and Coding Instructor at Community Care College