October 31, 2015

Bilateral Surgery Indicators for Breast Ultrasound Revised by CMS

As noted in the October 2015 Quarterly Update in the Medicare Physician Fee Schedule Database, bilateral surgery indicators for CPT® codes 76641(Ultrasound Breast Complete) and 76642 (Ultrasound Breast Limited) have been changed from “1” to”3.”

A bilateral surgery indicator of “1” subjects a procedure to a 150 percent payment adjustment, while indicator “3” states that the usual payment modification for bilateral procedures does not apply, i.e., no bilateral adjustment will be made.

Retroactive to January 1, 2015, Medicare will base the payment on the lower of the actual charge for each side or 100 percent of the fee schedule amount for each side for bilateral breast ultrasound procedures reported with modifier -50 or RT and LT. Bilateral surgery is defined as those procedures performed on both sides of the body in a single session or during the course of a single day.

Note that retroactive adjustments will not be made unless brought to the attention of the Medicare Administrative Contractor. Be sure to contact your MAC if any adjustments must be made. See Transmittal 3364 and MLN Matters article MM9266 for further details.

Please contact Dominick Parris in the Department of Economics and Health Policy with your questions at djparris@acr.org.