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.
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.
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.
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.
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