This policy addresses reimbursement for multiple surgeries and multiple endoscopy procedures performed as outlined below.
Multiple surgeries are separate procedures performed by the same physician on the same patient at the same operative session or on the same day. Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. Intraoperative services, incidental surgeries, or components of more major surgeries may not be billed separately.
Multiple endoscopic procedures performed on the same patient on the same day during the same session have special reimbursement rules applied by The Centers for Medicare & Medicaid Services (CMS).
BCBSND applies the same payment methodology for endoscopic procedures.
Endoscopic Base Procedure Code are located on the CMS National Physician Fee Schedule (PFS) Relative Value Unit (RVU) File in the endoscopic base code field.
Endoscopic Family is defined as all endoscopy codes that have the same endoscopic base procedure code.
Bilateral surgeries are procedures performed on both sides of the body at the same operative session or on the same day.
Multiple Surgery Policy:
Multiple procedures (Modifier 51) and/or bilateral procedures (Modifier 50) performed during the same operative session by the same physician or associate are reimbursed:
- 100% allowable for highest paying surgical procedure
- 50% allowable for all additional surgical procedures
- Procedures deemed to be Modifier 51-exempt (See AMA CPT Manual Appendix E)
- Procedures deemed to be add-on procedures (See AMA CPT Manual Appendix D)
- Services submitted with Modifier 78 or Modifier 55
- Procedures with a CMS Bilateral Status Indicator not applicable to the reduction. (See the Bilateral Procedure Reimbursement Policy)
- This policy may not apply to facility charges
- Obstetrical services
- Hemodialysis and peritoneal dialysis
Add-on procedures reported without a primary procedure will be denied as non-billable to the member by a participating, preferred, or network provider.
Individual consideration can be given to multiple surgical procedures performed by a physician and/or associate when the surgical procedure warrants physicians of different specialties. Medical records are required to be submitted for reimbursement determination in this situation.
Coverage for multiple surgical procedures is determined by individual or group customer benefits.
Multiple Endoscopies Policy
Endoscopies subject to the multiple endoscopy reduction can be identified with an indicator of ‘3’ in the Multiple Procedure field on the CMS PFS RVU File. The reduction occurs when an endoscopic procedure is billed with another endoscopic procedure in the same base endoscopy family.
Multiple endoscopy pricing rules will be applied to each base endoscopy family before ranking procedures performed on the same day, such as non-endoscopic procedures. When an endoscopic procedure is reported with only its base procedure code, no separate payment will be made for the base code. Payment for the base code is included in the payment for the other endoscopy. Additionally, when an endoscopic procedure is billed with procedures that are not endoscopies (i.e., surgical procedures), the Multiple Surgery Policy applies. After the multiple endoscopic reduction is ranked additional reimbursement policies will be ranked based on the service provided, for example Bilateral Procedures or Multiple Surgery Policy, etc.
Multiple Related Endoscopies (Same endoscopic base procedure)
- Determine the endoscopic procedure with the highest allowable rate and allow at 100%
- For each additional endoscopy within the family; allow the difference between the endoscopic base code’s allowed rate and the additional endoscopy code’s allowed rate
Two endoscopic procedures (Different endoscopic base procedures)
- In this scenario the Multiple Surgery Policy applies, and the multiple endoscopic reduction does not apply.
Four Endoscopies (Two different endoscopic base procedures)
- Follow the above calculation for determining each endoscopic family’s allowable amount
- Compare the total allowance for each endoscopic family
- The endoscopic family with the highest allowable amount will be allowable at 100%
- The remaining endoscopic family will be allowed at 50%
Bilateral, Multiple Endoscopy and Multiple Surgery can apply on the same line of a claim
- Bilateral calculation applies first
- Multiple endoscopy calculation applies next
- Multiple surgery calculation applies last
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
National PFS RVU File
Removed information about independent procedures as this is covered as part of National Correct Coding Initiative (NCCI) Editing Additional information about NCCI editing can be found in Correct Coding Guidelines.
Combined Multiple Surgery and Multiple Endoscopy into one policy. Added reference to the order calculations are applied when more than one reduction applies to the same line on a claim.