What coding guideline would you follow for a bilateral procedure?

For a bilateral procedure, the appropriate coding guideline is to use a bilateral modifier. This modifier indicates that a procedure has been performed on both sides of the body, helping to clarify the extent of the service provided. The use of a bilateral modifier is crucial for proper reimbursement and ensures accurate communication about the procedure to insurers.

When a procedure is identified as bilateral, it's typically noted in the code description or can be inferred from the nature of the procedure itself. By applying the bilateral modifier, the coder signals that the service was performed on both sides, which often has different coding implications than if only one side was addressed. This practice supports correct billing and avoids complications or denials during claims processing.

Modifiers should be used accurately as they can significantly influence payment and ensure appropriate documentation. In this case, opting for a unilateral modifier or not using any modifier at all would misrepresent the procedure performed, and using a global modifier may not apply, as global modifiers relate to services that are considered part of a surgical package rather than denoting sides of a procedure.