Description:
This policy addresses reimbursement for multiple surgeries performed as outlined below for all providers billing on the UB-04 Claim Form or CMS-1500 Claim Form.
Definitions:
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.
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
Exclusions
- 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
- This policy may not apply to facility charges
- Obstetrical services
- Hemodialysis and peritoneal dialysis
Additional Information
Add-on procedures reported without a primary procedure will be denied as non-billable to the member by a participating, preferred, or network provider.
Bilateral surgeries are procedures performed on both sides of the body at the same operative session or on the same day.
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 coverage determination in this situation.
Coverage for multiple surgical procedures is determined by individual or group customer benefits.
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.
Cross Reference:
Bilateral Procedures
History:
Date
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Revisions
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9/15/2020
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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.
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