Notification

Multiple Surgery Payment Reduction


Notification Issue Date: 12/30/2019


This version of the policy will become effective 03/30/2020.

This policy has been updated to communicate the Company's continuing position on multiple surgery payment reduction (MSPR).

Applicable codes have been added and removed from the policy to reflect codes that are subject to MSPR.



Claim Payment Policy


Title:Multiple Surgery Payment Reduction

Policy #:11.00.10w


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Multiple surgery payment reduction (MSPR) represents the Company's methodology to determine the professional provider's reimbursement when multiple surgical procedures are performed by the same professional provider or professional providers in the same provider group, on the same individual, during the same operative session, or on the same date of service.

MSPR is not applied to Current Procedural Terminology (CPT) procedure codes that are classified by the American Medical Association (AMA) as add-on codes or Modifier 51 exempt codes and Healthcare Common Procedure Coding System (HCPCS) codes classified by the Company as add-on codes.

Refer to Attachments A1 and A2 (CPT) and B (HCPCS) for procedure codes that are subject to MSPR.

The hierarchy for reimbursement of multiple surgical procedures is determined based on the professional provider's allowance for each surgical procedure, as set forth below:
  • The surgical procedure with the highest allowance is eligible for reimbursement at 100 percent of the provider's allowance.
  • Each subsequent surgical procedure(s) is eligible for reimbursement at 50 percent of the provider's allowance.

NON-COVERED SURGICAL PROCEDURES AND SURGICAL PROCEDURES NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

MSPR is not applied to surgical procedures that are non-covered or not eligible for separate reimbursement consideration. Surgical procedures that are non-covered or not eligible for separate reimbursement will process in accordance with the coverage and eligibility of the particular procedure(s) reported.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BILLING GUIDELINES


Multiple surgical procedures performed during the same operative session or on the same date of service, should be reported on a single claim form.

Inappropriate billing may result in claim overpayments and subsequent retractions or claim underpayments.


Description

A professional provider or professional providers in the same provider group may perform more than one surgical procedure on the same individual, during the same operative session, or on the same date of service. Therefore, the Company has established claims processing methodologies and guidelines for the reimbursement of multiple surgical procedures.


The Company defines surgery as the performance of generally accepted operative and cutting procedures including but not limited to specialized instrumentations, endoscopic examinations, and other procedures.

The American Medical Association (AMA) classifies certain Current Procedural Terminology (CPT) codes as add-on codes and Modifier 51 exempt codes.

An add-on code represents a supplemental procedure or service that is performed in addition to a primary procedure. Add-on codes are performed by the same professional provider who performed the primary procedure or service. Add-on codes are not stand-alone codes.

A Modifier 51 Exempt code may be a stand-alone code. However, when performed in conjunction with another surgical procedure it is not considered a multiple procedure.


References


Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/nonphysician practitioners. 40.6 - Claims for multiple surgeries. [CMS Web site]. Available at: https://www.cms.gov/files/document/medicare-claims-processing-manual-chapter-12 Accessed November 21, 2019.

American Medical Association (AMA). CPT Professional Edition: Current Procedural Terminology (Current Procedural Terminology, Professional Edition)2020 Edition.

Company Provider Manuals.

Company Benefit Contracts.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

REFER TO:
  • Attachment A1 or A2 for Current Procedural Terminology (CPT) codes to which multiple surgical reduction guidelines apply.
  • Refer to the CMS Physician Fee Schedules’ page to perform a search for CPT codes and the corresponding relative value units (RVUs), which is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html.


    Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

    Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


    ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

Attachment B




Revenue Code Number(s)

N/A


Coding and Billing Requirements


Cross References

Attachment A1: Multiple Surgery Payment Reduction
Description: Current Procedural Terminology (CPT) Codes To Which Multiple Surgery Payment Reduction Applies

Attachment A2: Multiple Surgery Payment Reduction
Description: Current Procedural Terminology (CPT) Codes To Which Multiple Surgery Payment Reduction Applies

Attachment B: Multiple Surgery Payment Reduction
Description: Healthcare Common Procedure Coding System (HCPCS) Codes To Which Multiple Surgery Payment Reduction Applies



Policy History

11.00.10w
03/30/2020This version of the policy will become effective 03/30/2020.

This policy has been updated to communicate the Company's continuing position on multiple surgery payment reduction (MSPR).

Applicable codes have been added and removed from the policy to reflect codes that are subject to MSPR.

11.00.10v
01/01/2020This policy has been identified for the Annual Code Update. This version of the policy will become effective 01/01/2020.

The following codes have been added to this policy:

0563T, 0565T, 0566T, 0567T, 0568T, 0569T, 0571T, 0572T, 0573T, 0574T, 0575T, 0580T, 0581T, 0582T, 0583T, 0584T, 0585T, 0586T, 0587T, 0588T, 15769, 15771, 15773, 20560, 20561, 20700, 21601, 21602, 21603, 33016, 33017, 33018, 33019, 33858, 33859, 33871, 34718, 35702, 35703, 46948, 49013, 49014, 62328, 62329, 64451, 64454, 64624, 64625, 66987, 66988

The following codes has been deleted from this policy:

0249T, 0254T, 0375T, 0377T, 19260, 19271, 19272, 19304, 20926, 33010, 33011, 33015, 33860, 33870, 35721, 35741, 35761, 43401, 64402, 64410, 64413

The following code narratives have been revised in this policy:

31233, 31235, 31292, 31293, 31294, 31295, 31296, 31297, 35701, 46945, 46946, 54640, 62270, 62272, 64400, 64405, 64408, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, 64450, 66711, 66982, 66984

Version Effective Date: 03/30/2020
Version Issued Date: 03/30/2020
Version Reissued Date: N/A



2017 AmeriHealth.