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Multiple Procedure Reimbursement

  1. Default Multiple Procedure Reimbursement
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    Medicare indicates that they pay "100% of the highest physician fee schedule amount & 50% of the physician fee schedule amount for each of the other codes". Does anyone know if all insurance carriers follow this rule? Are you familiar with any that do not? Lastly, does anyone have insight as far as the primary procedure performed (which may have a lower allowable) being paid at 100% while another procedure (with the higher allowable) being paid at 50%? I realize some of you may be located in a different geographical area, but any feedback will be helpful.


    Brandy Nyberg

  2. #2
    Charlotte, NC
    Carrier policies vary. Many rank by RVU rather than fee. The % of reimbursement for 2nd and subsequent procedures also varies. Some use 100/50/50; others use 100/50/25, etc. The "better" carriers will publish a policy to clearly outline their rules -- see UHC: https://www.unitedhealthcareonline.c...10F_111510.htm

    Hope that helps!

  3. #3
    BCBS and Aetna also have published policies on this. (Cigna may, but their website's a pain in the butt, in my opinion). I can tell you that they cover 100%/50% each additional (of contracted rate) from experience, though. Try searching for "Multiple Surgery", "MSP", and "Multiple Procedure". within their clinical and reimbursement policies. I know that for BCBS/TX, this particular rule is located in its own little section away from the clinical policies. They apply these policies to E/M services, as well, so read carefully.

  4. Default
    Thanks for your input. Our UHC rep also stated there is a Multiple Procedure book out there explaining what they go by. She couldn't remember the name of it. Anyone familiar with this publication?

  5. #5
    Hopefully this link works...


    There's not a login required to get to this page, but the policy is HUGE...

  6. #6
    Medical Billing
    Okay I don't think it does work...So, go to:

    Under "Tools and Resources", select "Policies & Protocols"

    On the Right side of the page, click "Reimbursement Policies" - And then agree to the terms.

    Scroll down and you'll see the link for Multiple Procedures, and that's the policy. It has links to outside sources that they cited for their rationale.

    ***The first link DOES work, as long as you click "No" when the page asks you if you only want secure information to be displayed.***
    Last edited by btadlock1; 12-14-2010 at 11:39 AM. Reason: Added last note

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