Wiki Multiple Procedure Payment Reduction?

[rbassett]

When performing multiple procedures in the same operative session by the same provider, the 2nd, 3rd, 4th etc procedures get reduced by 50%, 25%, 25% etc. Does that still apply when they are done on separate structures?

Example:
67040 RT = paid at 100%
67228 LT = paid at 50% or 100%


Thanks.

 

[CodingKing]

Yes it applies even if its separate structures, incisions etc. The only time it doesn't is for designated add on-codes and codes listed as modifier 51 exempt in the CPT book.

 

[skiboi]

CodingKing
If I'm understanding your response correctly that would mean that when we perform 64483 & 64484 and bill professionally, we would not expect to see a reduction on the add-on code 64484 and they should pay the allowed amount for that payer? And lets use Noridian/Medicare as an example here.
Thank you

 

[thomas7331]

That's correct - 64484 is an add-on so is never subject to multiple procedure reductions under CMS reimbursement rules.

 

[edie814]

That is usually correct but based on your contract . I am employed by the payor so there are many contracts out now that are not grouper based and pay by %. If it pays by percentage you usually get the percentage of total billed charges up to a max no matter how many procedures are billed . and Implants and high cost drugs may or may not be included in max I also have one ASC contract that pays 100/50/25/25 but medicare standard is 100/50/50/25 and there is sometimes even a max to them.