Notification



Notification Issue Date:



Claim Payment Policy


Title:Multiple Surgical Reduction Guidelines (Independence)

Policy #:11.00.10u

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

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 Evidence of Coverage.

As the Company transitions from the Independence Blue Cross (IBC) claims processing platform to the Highmark claims processing platform over the next couple of years, IBC membership will be migrated to the Highmark platform in stages, generally based on the customer/member health benefit renewal cycle. During this transition period, claims for multiple surgical procedures processed on or after November 1, 2013 will be processed using two methodologies to determine the hierarchy for reimbursement of each surgical procedure. Therefore, professional providers may see a difference in the processing of claims for multiple surgical procedures depending upon whether the claim processes on the IBC platform or the Highmark platform.

Multiple surgical reduction guidelines apply to multiple surgical procedures 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 in all places of service (eg, inpatient, outpatient). Multiple surgical reduction guidelines represent a methodology used to determine the provider's reimbursement for eligible multiple surgeries.

Multiple surgery reduction guidelines are not applied to procedures that are classified by the American Medical Association (AMA) Current Procedural Terminology (CPT) as add-on codes or Modifier 51-exempt codes.

Refer to Attachments A1, A2, and B for lists of procedure codes to which multiple surgical reduction guidelines apply.

On or after November 1, 2013, the Company will apply one of the two following methodologies depending upon the claims processing platform to determine the hierarchy for reimbursement for claims received from professional providers for multiple surgical procedures, regardless of place of service:

IBC CLAIM PROCESSING PLATFORM:

Surgical ranking is determined using the relative value unit (RVU) listed in the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Fully Implemented Non-Facility Total-Column for each surgical procedure code on the claim.
  • The RVU for each procedure code is rounded to the closest whole number (eg, 11.49 is rounded to 11, 11.50 is rounded to 12).
  • The resulting whole number is subtracted from 1000 to determine the surgical ranking.
    • The lower the difference between these two numbers, the higher the surgical ranking of the code (ie, the lowest surgical rank is 999, and the highest surgical rank is one)
      • This method of surgical ranking is a requirement of the Company's current claims processing systems for professional providers.
  • The procedure code with the highest surgical rank is the highest-valued procedure.
  • The following multiple surgical reduction percentages are applied to the other ranked surgical procedures:
    • The highest-valued procedure is eligible for reimbursement at 100 percent of the provider's applicable contracted rate.
    • Each remaining procedure(s) is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.
  • If, as a result of the above methodology, two or more procedures have the same surgical rank, the Company determines the highest-valued procedure to be the surgical procedure with the highest-billed dollar amount.

The individual professional provider's applicable contracted rate is not utilized in the methodology to determine the highest-valued procedure for claims processed on the IBC claim processing platform.

NONCOVERED SURGICAL PROCEDURES AND SURGICAL PROCEDURES NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

Surgical procedure codes are ranked independently from eligibility and reimbursement. As a result, there may be infrequent instances when a noncovered surgical service or one that is not eligible for separate reimbursement may, in accordance with the above methodology, be designated as the highest-valued procedure. In such cases, the remaining covered surgical procedure(s) are eligible for reimbursement at 50 percent of the provider's applicable contracted rate. Types of surgical services that are not eligible for separate reimbursement include, but are not limited to, clinically incidental and mutually exclusive procedures.
  • An incidental procedure is a procedure that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure.
  • Mutually exclusive procedures are combinations of two or more procedures that are performed by the same provider, on the same individual, during the same operative session, and on the same date of service that differ in technique or approach but lead to the same outcome and may be described as being one of the following:
    • A combination of procedures that is anatomically impossible
    • Overlapping procedures
    • Duplicate procedures
    • When one procedure code narrative describes an initial service and the other procedure code describes a subsequent service

Professional providers may appeal claims processing outcomes when the highest-valued procedure is a noncovered surgical procedure or one that is not eligible for separate reimbursement. For professional provider appeals information, refer to the Provider Manual and other appeals information that has been issued by the Company.

HIGHMARK CLAIM PROCESSING PLATFORM:

The hierarchy for reimbursement of eligible multiple surgical procedures on the Highmark platform will be based on the procedure reported "allowed amount", not the derived "surgical ranking" that is currently used on the IBC platform. The hierarchy for reimbursement of multiple surgical procedures is determined based on the provider's allowed amount for each surgical service, as set forth below:
  • The surgical procedure with the highest allowed amount is considered the primary procedure.
  • The following multiple surgical reduction percentages are applied to each subsequent surgical procedures:
    • The surgical procedure with the highest allowed amount/primary procedure is eligible for reimbursement at 100 percent of the provider's allowance.
    • Each remaining surgical procedure(s) is eligible for reimbursement at 50 percent of the provider's allowance.

NONCOVERED SURGICAL PROCEDURES AND SURGICAL PROCEDURES NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

Multiple surgical reduction guidelines are not applied to surgical services that are noncovered or not eligible for separate reimbursement consideration. When surgical services that are noncovered or not eligible for separate reimbursement are reported, the services will process in accordance with the coverage and eligibility of the particular procedure(s).

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

This claim payment rationale applies only to the codes or code combinations listed in the attachments to this policy and does not apply to any other codes and/or code combinations. Claims are processed according to the statements in this policy. When a medical policy on the performed surgical procedure(s) exist, the medical necessity criteria listed in that medical policy must also be met.

BILLING GUIDELINES

In order to receive the appropriate reimbursement, whether claims are processed on the Independence Blue Cross (IBC) or Highmark claims processing platforms, multiple surgical procedures should be reported as follows:
  • For surgical procedures performed during the same operative session or on the same date of service, the professional provider should submit a claim form with the multiple surgical procedure code(s) for the services performed on a single claim form.
  • For surgical procedures performed on different dates of service, the professional provider should submit a separate claim form for each date of service with the multiple surgical procedure code(s) for the services performed.

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 submit claims for multiple surgical procedures performed 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 performed by professional providers. The application of these methodologies and guidelines determine the hierarchy for reimbursement of each surgical procedure.

Multiple surgical reduction guidelines apply to surgical procedures, which are generally accepted operative and cutting procedures including specialized instrumentations, endoscopic examinations, and other procedures (eg, debridement of burns, percutaneous fixation of fractures).
References


Independence Blue Cross (IBX). Provider News Center. Business Transformation: Important Information about Our Claims Processing System Transformation. [IBX Web site]. May 22, 2013. Available at: http://provcomm.ibx.com/ProvComm/ProvComm.nsf/IBCNewsCenterCat!OpenView&Start=1&Count=200&CollapseView&RestrictToCategory=Business%20Transformation. Accessed June 28, 2013.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/nonphysician practitioners. 40.6 - Claims for multiple surgeries. [CMS Web site]. 03/29/2013. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed May 7, 2013.

Company Provider Manuals.

Novitas Solutions Medicare Services. Medicare A/B Reference Manual. Chapter 22: Global surgery and related services. [Novitas Solutions Medicare Services Web site]. Available at: https://www.novitas-solutions.com/refman/chapter-22.html. Accessed May 7, 2013.

McKesson, Corp. Clear Claim Connection™ (C3). Glossary. 2013. Accessed May 7, 2013.

New Jersey (NJ) Department of Banking and Insurance (DOBI). Health care provider application to appeal a claims determination. [NJ DOBI Web site]. July 2006. Available at: http://www.newjersey.gov/dobi/chap352/352genapplication.doc. Accessed September 8, 2009.

State of Delaware. Delaware administrative code. Title 18 insurance code. 1300 health insurance general provisions. 1311 standards of payment for multiple surgical procedures [formerly Regulation 82]. [Delaware Administrative Code Web site]. 01/01/2000. Available at: http://regulations.delaware.gov/AdminCode/title18/1300/1311.shtml. Accessed August 28, 2009.




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)

REFER TO:

    • Attachment B for Healthcare Common Procedure Coding System (HCPCS) codes to which multiple surgical reduction guidelines apply.




Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A1: Multiple Surgical Reduction Guidelines (Independence)
Description: Current Procedural Terminology (CPT) Codes To Which Multiple Surgical Reduction Guidelines Apply

Attachment A2: Multiple Surgical Reduction Guidelines (Independence)
Description: Current Procedural Terminology (CPT) Codes To Which Multiple Surgical Reduction Guidelines Apply

Attachment B: Multiple Surgical Reduction Guidelines (Independence)
Description: Healthcare Common Procedure Coding System (HCPCS) Codes To Which Multiple Surgical Reduction Guidelines Apply



Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 01/01/2017
Version Issued Date: 01/06/2017
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.