Understanding the Multiple Procedures Rule
- By John Verhovshek
- In Coding
- August 21, 2014
- 19 Comments
When providers report multiple procedures during a single encounter, payers typically will reimburse only the highest-valued procedure at full fee schedule value, and will reduce payment for the second and subsequent procedures. This occurs because payers reason that many of the component services that comprise the physician’s work (such as surgical approach and closure) should be paid only one time, per session. Chapter 1 of the National Correct Coding Initiative (NCCI) Policy Manual explains:
Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. When multiple procedures are performed at the same patient encounter, there is often overlap of the pre-procedure and post-procedure work. Payment methodologies for surgical procedures account for the overlap of the pre-procedure and post-procedure work.
This is the basis for the Medicare multiple procedure rule, under which the Centers for Medicare & Medicaid Services (CMS) pays a reduced amount for the second and subsequent procedures performed during the same session. The amount of the reduction (if any) is determined by the indicator within the “Multiple Procedure” column of the Physician Fee Scheduled Relative Value file:
0=No payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure, base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount for the procedure.
1=Standard payment adjustment rules in effect before January 1, 1995 for multiple procedures apply. In the 1995 file, this indicator only applies to codes with a status code of “D”. If procedure is reported on the same day as another procedure that has an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 25%, 25%, 25%, and by report). Base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage.
2=Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50% and by report). Base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage.
3=Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in the Endobase field of this file. Apply the multiple endoscopy rules to a family before ranking the family with the other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure. Payment for the base procedure is included in the payment for the other endoscopy.
4=Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging procedure in the same family (per the diagnostic imaging family indicator, below). If procedure is reported in the same session on the same day as another procedure with the same family indicator, rank the procedures by fee schedule amount for the TC. Pay 100% for the highest priced procedure, and 75% for each subsequent procedure. Base the payment for subsequent procedures on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage. The professional component (PC) is paid at 100% for all procedures.
9=Concept does not apply.
The multiple procedure rule does not apply to all CPT® codes. According to the multiple procedure rule guidelines, payers should never reduce payment for:
- Significant, separately identifiable E/M services provided on the same day as other procedures/services and properly appended with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service
- Any designated “add-on” CPT® code (listed with a “+” next to the descriptor)
- Any procedure designated by CPT as “Modifier 51 exempt,” which may be identified in the CPT code book by a “circle with a slash” next to the code.
You can find a full list of add-on and modifier 51 exempt procedures in Appendices D and E of the CPT® code book. The relative values assigned to these codes factor in the “additional” nature of the procedure/services; therefore, there is no justification to reduce reimbursement when these codes are reported in addition to other procedures.
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I need advise on how to bill all these surgeries performed at the same time by one surgeon.
Can you help me?
Laparoscopic Lysis of Adhesions
Robotic Sacrocolpopexy
Right Salpingo-oophorectomy
Moscowitz Cul De Sac Obliteration
Cystoscopy
Perineoplasty
We bill frequently for multiple procedures on the same date of service with appropriate modifiers. However can you clarify if these services have to be submitted on the same claim form? (when billing for professional services).
Thank you
Can you explain me the multiple surgery rule.
Actually we have billed the 28615RT, 27768-51RT, 28555-51RT, 28465-51RT , but we have only received payment of $280.67 for CPT 28615 which is our primary procedure. It is medical patient. As per medical this procedure should be paid in the amount of $567.01. they have given us the description that multiple or concurrent procedure rule.
Hi,
Could you please confirm whether we can have Multiple Surgery reduction rule applicable for the RADIOLOGY CPT codes.
If so please advise us.
Thanks,
Kumaran
If a doctor performs surgery in which multiple incisions are made on different parts of the body are these going to be under the multiple surgery rule or would each one be paid at 100% since they are not related? Per the doctor he: Femoral artery thrombectomy by groin incision, popliteal and tibial artery thrombectomies by below knee popliteal incision and fasciotomies by yet more incisions. If I add add modifier XS would this be adequate to get paid correctly?
Thank you for any advice you can add..
Delynn
I realize the multiple procedure billing rule is designed to save the PAYER, but it pushes the DOCTORS to schedule procedures on multiple days just so they can bill each procedure in full. I am a PATIENT, what about the time, the cost and the inconvenience to me. Years ago I could get multiple procedures that the doctor requested in one visit, saving me time and getting the tests done that the doctor required. Now I have to take 5 days off of work, which is costly and inconvenient to say the least. Let me explain.
Day 1 Doctors initial visit, he orders 3 tests (Stress Test, Echo of the heart, Echo of the Carotid artery)
Day 2 Stress Test
Day 3 Echo of Heart
Day 4 Echo of Caratid
Day Doctor’s Visit to review tests
Does that seem wasteful to anyone other than myself?
If you perform a 96372, mod 59, and then do a joint injection with 20610 x 2, can someone explain payments? I believe 96372 should be 100%, the first unit of 20610 should be 100% and the 2nd unit of 20610 at 50%…can someone please comment about that?
Can someone please explain what is meant by the statement “Base the payment on the lower of the actual charge” in this article? Please give an easy to understand example.
Thank You, Aleece
CPT code 64640 has the procedure or service multiple procedure reduction applies
procedure :sacroiliac joint radiofrequency ablation of RT L5 dorsal ramus, S1, S2 and S3 lateral branches
Would this be coded as
64635-RT
64640- 51 RT
64640-51 RT
64640-51 RT
does anyone have any information on how the multiple surgery rules are applied to mod AS in Illinois? since the reimbursement is based on minutes would it still apply?
I don’t understand the multiple procedure indicator 3 for endoscopy procedures. Can you explain further? If I bill 45385 and 45380/59 would I use a 51 also on 45380?
BCBS of Texas is using this multiple procedure rule for this; 4 procedures were billed at same surgery day, 1st one is labeled as primary because it pays the most allowable but they deny it as being bundled to secondary. And they only pay the secondary at 50%. Should they not have paid the secondary at 100% if primary was bundled into it.? Help
Question regarding Multiple Procedure Reduction for Inpatient services. We have a payor who is applying this Multiple reduction to CT scans with our Inpatient services. IS this correct or should it only apply to Outpatient services such as radiology and surgery services?
CPT-46220 – blue shield as This procedure is included with payment for another procedure performed on the same day , Blue Cross denied as Service is denied because it is incidental based on the National Correct Coding Initiative (NCCI) as published/maintained by CMS(we have Submitted the claim with 59 modifier for the cpt 46220.
Why this denial receiving what is the solution for this denial
I am stuck w a claim
99214,25
69210,50
96372
J3301
all supported by separate diagnoses
patient was going to travel all needed tp be [performed
prior
thank you for the help
Even with mod 25, Aetna paid me $7 for 99213 because it was done with physical of patient. This insulting behavior to physicians causes total disregard of patints’ medical problems during their physical.
Why indicator number 5 is not listed?
5 = Selected therapy services subject to MPPR methodology. Subject to 20 percent of the practice
expense component for certain therapy services furnished in office or other non-institutional settings, and 25
percent reduction of the practice expense component for certain therapy services furnished in institutional
settings (effective for services January 1, 2011, and after). Subject to 50 percent reduction of the practice
expense component for certain therapy services furnished in both institutional and non-institutional settings
(effective for services April 1, 2013, and after).
Hi.. somebody knows if multiple surgery rule apply to a single physician or to physicians on the same group.
E.g. If CPT 54405 is reported by one surgeon and 54110 is reported by a different surgeon with the same specialty but they are in the same group practice, do I have to pay both at 100% MCA or do I have to apply multiple surgery rule?
Is there such a rule for Radiology procedure billed with Modifier 51 as secondary Modifier to pay at 5% Reduction from allowable?
Please, clarify if possible??
Thank you