Reimbursements

Category:

Multiple Surgeries

Reimbursement Policy: NDRP-Surg-007
Topic: Surgery
Effective Date: July 1, 2018
Last Reviewed:
September 4, 2019

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

Independent procedures (i.e., separate procedures, as noted in the AMA CPT © Codebook) are procedures commonly performed with other major (primary) surgical procedures. When multiple independent procedures are performed, payment will be made only for the highest paying independent procedure.

Payment for independent procedure can be made when:

The sole surgical procedure performed; or
The highest paying of multiple surgical procedures performed (any additional, covered non-independent procedures can be paid at 50%).

When a procedure or service is designated as a separate procedure it is carried out independently or considered to be unrelated or distinct from other procedures/services provided at that time. It may be reported by itself or in addition to other procedures/services by appending modifier 59, XE, XP, XS or XU to the specific separate procedure code. The modifier indicates that the procedure is not considered to be a component of another procedure, but is a distinct and independent procedure.

Independent procedures are eligible for payment under the following circumstances when reported with modifiers 59, XE, XP, XS or XU:

Different operative session on same date of service; or
Different site or separate area of injury; or
Separate incision; or
Different body orifices; or
Bilateral procedures.

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.