Modifier 50 is used to report a bilateral procedure. This modifier is only to be appended to a CPT code when the same procedure is performed on both sides of the body during the same operative session. Modifier 50 is not applicable with procedures that are bilateral in nature or where the descriptions include the terminology bilateral or unilateral.
Reading the description of each code, referencing CPT lay descriptions, checking fee schedules and/or using coding software can help to determine if a modifier 50 is appropriate to use. If the code description does not reference a body part that is dual in nature, modifier 50 may not be appended. In most cases each procedure must be performed through its own separate incision to qualify for the bilateral modifier.
An example of a bilateral procedure is a tonsillectomy, during this procedure both sides of the tonsils are removed, modifier 50 does not need to be appended because this procedure includes the removal of both sides of the tonsils, a separate incision is not made, and the code edit informs the coder a bilateral modifier is not appropriate.
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