This is an example only.  Please adapt to your billing situation.

In this case a physician orders a bilateral eye socket X-ray.  This claim example illustrates the billing of a bilateral radiographic procedure with a unilateral code.

In the Reserved for Local Use field (Box 19), enter a statement declaring a bilateral procedure was done but was billed with a unilateral code.

In this example, Procedure-4 code 70190 (radiologic examination; optic foramina) is billed with modifier TC (technical component) in the Procedures, Services or Supplies field (Box 24D).

In the Date(s) of Service field (Box 24A), the date of the office visit, June 7, 2007 is entered on claim line 1 as 060707.  Enter Place of Service code 11 (office) in Box 24B.

Enter the referring provider name in the Name of Referring Provider or Other Source field (Box 17) and the referring provider’s NPI in
Box 17B.  Enter the rendering provider’s information in Service Facility Location Information field (Box 32) and the NPI in Box 32A.

Enter the usual and customary charges in the Charges field
(Box 24F).  Enter a 2 in the Days or Units field (Box 24G) for code 70190.  This number indicates the procedure is bilateral. Enter in the Reserved for Local Use field (Box 19) that the procedure was performed bilaterally.