In podiatry billing, understanding the bilateral billing rules for foot procedures is essential for addressing claim denials. In 2026, payers are becoming more stringent about specificity and require podiatry surgeons to document whether the procedure performed was unilateral or bilateral. In this blog, we will specifically discuss the billing rules that you must follow when doing bilateral procedures. This billing guide will help you accurately create and submit medical claims to the relevant payers on time. Without further ado, let’s get started.
Understanding Bilateral vs Unilateral Procedures
In podiatry billing, bilateral and unilateral procedure terminologies are commonly used. These terminologies are not only used for clinical documentation but mainly for billing purposes, where they describe at which place/leg the procedure is carried out. For healthcare professionals, this means that they have performed the same surgical procedure on both sides of the leg, ankle, or foot.
In contrast, unilateral podiatry surgery details a procedure that is done on one leg, ankle, or foot. Unilateral procedures require a modifier like -LT, meaning the left leg, or -RT, meaning the right leg, received medical care from the physician. In medical billing, this plays a vital role since providers cannot get paid or receive underpayment if they performed a bilateral procedure and bill for a unilateral one. These are some of the most common billing mistakes, resulting in denials, underpayments, and rejections.
Clinical vs. Billing Definition
Clinical and billing definition both means the same as both sides. In medical claims, it helps insurance companies process the claim and pay the fair amount for this lengthy procedure since it is performed on both sides.
The billing definition further clarifies the term and provides more detailed information, like a surgical procedure performed on two identical structures (e.g., the right 1st metatarsal and the left 1st metatarsal). In short, podiatry bilateral billing shows to payers that two identical anatomical sites are treated at the same time, day, or separately, one after the other.
Besides the basic understanding of the billing, it is helpful for foot and ankle surgeons to add two separate strile fields in the claim. In bilateral surgery, two separate incisions are made, requiring two separate sterile setups. Modifier for this must be added in the claim so that the accurate amount is reimbursed.
Common Bilateral Procedures
To name a few, these are the foot and ankle surgery examples that are commonly billed in bilateral procedure billing, including:
Routine Foot Care
- Nail debridement (CPT 11720, 11721)
- Corn/callus removal (CPT 11055–11057)
Wound Care
- Debridement of ulcers or infected tissue (CPT 97597–97598)
- Dressing changes or wound management on both feet
Injections
- Corticosteroid injections for plantar fasciitis or neuromas
- Local anesthetic injections for bilateral procedures
Surgical Procedures
- Bunionectomy (CPT 28296, 28297) performed on both feet
- Hammertoe correction (CPT 28285) on multiple toes across both feet
- Tendon repair or transfer procedures, when done bilaterally
- Excision of lesions or cysts on both feet
Orthotic/Supportive Care
- Casting or strapping when applied to both feet
- Orthotic fitting when bilateral
Key Billing Modifiers in Podiatry
Podiatry medical billing for bilateral procedures is typically complemented by modifiers, since they define the position as well as the specificity of the procedure that was performed on both feet. Let’s get to know these modifiers for such procedures.
Modifier -50 (bilateral)
Podiatry modifier -50 guidelines 2026 state that it must be used when a procedure was performed bilaterally. The use of this indicates that surgery or a medical procedure was performed on both sides of the leg during the same session. By adding a -50 modifier, podiatrists are basically claiming that both feet are checked and have undergone the surgery under one encounter.
Examples
The example for modifier 50 for bilateral procedures includes:
- Nail debridement (CPT 11720 – debridement of one nail). If performed on both feet, you would append -50 to show it was bilateral.
- Bunionectomy (CPT 28296). If performed on both feet in the same session, modifier -50 is added.
Modifier -LT (left foot) and -RT (right foot)
In foot procedure billing modifiers, this one is one of the most important ones because it describes the anatomical location of the leg where the procedure was performed. -LT means left side, and -RT means right side. As per podiatry billing guidelines, it is applied to CPT/HCPCS codes when a procedure can be performed on either foot.
Examples
The way to use LT and RT modifiers in podiatry can be better understood by the following example:
11720 (debridement of one nail)
- If done on the left foot → 11720-LT
- If done on the right foot → 11720-RT
If the procedure is performed on both feet, you submit two line items:
- 11720-LT
- 11720-RT
Medicare vs Private Insurers
Bilateral billing rules for foot procedures vary between Medicare and commercial payers. Medicare prefers to accept -LT and -RT for bilateral procedures (two separate claim lines). On the other hand, private insurance companies accept Modifier -50 (bilateral) instead of separate LT/RT lines. It is recommended to thoroughly check payer-specific foot care reimbursement policies to prevent claim denials.
When to Use Separate Line Items vs Modifier -50
Modifier -50
This modifier is used when the same medical procedure is performed on both feet/legs in one session. The payer accepts one line item with -50 to indicate bilateral service. Some insurers pay 100% reimbursement for the first side and 50% for the second side. Typically, all major insurers pay 100% for bilateral surgeries.
Example:
CPT 28296 (bunionectomy) performed on both feet → 28296-50.
Separate Line Items (-LT and -RT)
Medicare podiatry billing rules apply differently in some instances when the same procedure is performed on both sides of the foot; payers want each procedure to be billed as separate line items. Podiatrists need to specify the laterality (left vs right).
Example:
CPT 11720 (nail debridement) performed on both feet →
- 11720-LT
- 11720-RT
The reimbursement process for such claims is easy, and Medicare typically pays the full fee for each line item without deductions. This type of billing is best for insurers, government, or private who reject -50.
Comparison Table
The following table best illustrates the situation where podiatry practices can use modifier -50 and a separate line item where required.
| Situation | Modifier -50 | Separate Line Items (-LT/-RT) |
| Both feet treated | One line item with -50 | Two line items (one LT, one RT) |
| Medicare | Not accepted | Required |
| Private insurers | Sometimes accepted | Sometimes required |
| Documentation | Procedure performed bilaterally | Procedure performed on left foot + Procedure performed on right foot |
Medicare and Insurance Guidelines
There are various rules for reimbursement for bilateral foot surgery, depending on the health plan provider, such as Medicare or private insurers. Let’s discuss some of the core podiatry medical coding best practices and what the guidelines say about them.
Medicare Guidelines for Podiatry Billing
As per the 2026 podiatry billing guidelines, Medicare (Part B) excludes routine foot care (nail trimming, callus paring) unless the patient is suffering from a systemic condition that makes self-care dangerous or contraindicated. For billing patients on routine care, a provider must ensure that the patient is under the active care of an MD or DO for a complicating systemic disease (like Diabetes or PVD).
Additionally, podiatry surgeons must record all the relevant patient and their treatment data with the last seen dates within the 6 months before the podiatry visit or referral. While adding charge captures, enter the primary physician’s NPI in Box 19 of the CMS-1500 form.
Mandatory “Class Findings” (Q Modifiers)
Modifiers are an essential component of podiatry billing for multiple digits. In order to receive payments from Medicare for a procedure having CPT 11721 (nail debridement) or 11055 (callus paring), your physical exam must document specific “Class Findings” to justify the Q7, Q8, or Q9 modifiers: Here’s the breakdown of Q modifiers and when to add them.
Q7 Class A: Nontraumatic amputation. Routine nail debridement for a diabetic patient with an absent dorsalis pedis pulse.
Q8 Class B: Absent pulses (PT or DP) or trophic changes (hair loss, nail thickening, skin discoloration). Callus removal in a patient with thickened nails and skin atrophy.
Q9 Class C: Claudication, temperature changes (cold feet), edema, paresthesia, pain, infection, or other severe complications.
Private Insurance Guidelines
For sending claims to private insurers, the procedure is not as straightforward as Medicare. These are steps that you must take to ensure an uninterrupted cash flow and accurate billing:
Prior Authorization
For private insurance companies, the podiatry billing team must obtain pre-authorization for specific procedures or surgeries like (bunionectomies) and custom orthotics (L-codes), etc.
Routine Care Coverage
Routine care treatments are considered maintenance services rather than medical necessities. In the case of private insurers, some premium commercial plans besides Medicare Advantage (Part C) plans may offer limited routine foot care as a wellness benefit, even without a systemic disease.
Remote Patient Monitoring / Telehealth
Many private insurers allow podiatrists to offer RPM or telehealth services to patients suffering from amputations or debilitating conditions. Providers can easily bill these patients following prescribed protocols, allowing for more frequent digital check-ins for chronic wound care.
Comparison of Billing Rules (2026 Update)
Here’s a short comparison of bilateral podiatry billing rules in 2026, offering valuable information for billing your patients.
| Feature | Medicare (Original) | Private / Medicare Advantage |
| Routine Care | Only with systemic disease + Q modifiers. | Varies; often requires Pre-Auth for any “extra” care. |
| Surgery Payment | 100% of Fee Schedule (minus deductible). | Often follows a “Multiple Procedure” reduction (50% for 2nd). |
| Orthotics | Generally not covered unless for diabetic shoes. | Often covered if “Medically Necessary” with Pre-Auth. |
| Bilateral Rules | Uses Indicator 1 (Modifier 50 pays 150%). | May require separate lines (RT/LT) instead of -50. |
“Audit-Proof” Documentation Standards
Every year, reimbursement policies are getting stricter, and getting full payments from insurers is becoming tricky. Foot and ankle care hospitals must ensure their bilateral procedure billing is free of errors and discrepancies. Providers can improve their billing documentation by taking the steps mentioned below:
The “Golden Rule” of Medical Necessity
Providing medical necessity justification is the first step towards errorless billing for podiatry procedures, either unilateral or bilateral. By proving that the bilateral surgery you have performed was not only necessary but also improved the quality of life, providers can expedite the reimbursement process.
Avoid “Cloned” Notes
It is prudent to avoid using the same words in every case presentation related to bunionectomy. Each clinical note should be unique and paint a different picture than the previous bunion surgery you have performed. The same paragraphs create a sense of lacking authenticity and attention, raising questions about the provider’s intention. Your clinical notes should demonstrate the importance of medical treatment that was provided rather than seen by payers as a “personal hygiene” service.
Documenting the “Risk of Non-Treatment”
Podiatrists must provide detailed clinical notes detailing the entire life span of the systemic conditions and the damage they have caused to the patient. Presenting clinical documents detailing what would happen if the treatment were not performed helps build the case (e.g., “Patient at high risk for ulceration due to severe onychauxis and peripheral neuropathy.”)
The 6-Month MD/DO Rule
Providers must enter the details related to the name of the primary care physician, MD/DO treating the patient, and the last seen date (within the last 6 months). This step not only strengthens the collaboration with the patient’s physician and podiatrist in improving the symptomatic treatment, but also keeps the primary care provider updated on their patient’s condition.
Conclusion
Understanding the bilateral billing rules for foot procedures helps solo and group podiatry practices to improve their billing and coding practices. Following Medicare and commercial payer guidelines facilitates faster reimbursements. Besides billing and coding, podiatry surgeons should also maintain spotless clinical documentation for accurate data recording of surgical outcomes, ultimately leading to improvement in the quality of life.
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