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Multiple Surgery Payment Reduction
11.00.10y

Policy

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 on the same individual, during the same operative session, or on the same date of service.

The Company applies MSPR to Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes that represent surgical procedures. 

MSPR is not applied to CPT procedure codes that are classified by the American Medical Association (AMA) as add-on codes or Modifier 51 exempt codes and HCPCS codes classified by the Company as add-on codes.
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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% of the provider's allowance.
  • Each subsequent surgical procedure(s) is eligible for reimbursement at 50% of the provider's allowance.
NONCOVERED SURGICAL PROCEDURES AND SURGICAL PROCEDURES NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

MSPR is not applied to surgical procedures that are Misspelled Wordnon-covered or not eligible for separate reimbursement consideration.

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 professional provider'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, by the same professional provider, should be reported on a single claim form.

Modifier -51 should be appended to multiple procedure codes performed on the same individual, during the same operative session, or on the same date of service by the same professional provider.

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

Description

A professional provider 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: Medicare Claims Processing Manual. Chapter 12: Physicians/nonphysician practitioners. 40.6 - Claims for multiple surgeries. Accessed November 08, 2024.

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

Company Provider Manuals.

Company Benefit Contracts.

Coding

CPT Procedure Code Number(s)

N/A​​​

ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)

N/A​​

Revenue Code Number(s)
N/A

Modifiers

51 Multiple Procedures

Coding and Billing Requirements

Policy History

Revisions From 11.00.10y:
12/30/2024This policy will become effective 12/30/2024. The policy has been updated to clarify codes subject to Multiple Surgical Procedure Reductions (MSPR) as well as guidelines for reporting multiple surgical procedures using modifier -51.

Procedure codes have been removed from this policy. A policy statement has been added to address codes that are potentially subject to MSPR.

Modifier -51 has been added to the coding table.

Revisions From 11.00.10x:
11/02/2022
The policy has been reviewed and reissued to communicate the Company’s continuing position on Multiple Surgery Payment Reduction.
01/01/2021
This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021.

The following procedure codes have been added to attachmnts A1 and A2 of this policy:
0620T, 0621T, 0622T, 0627T, 0628T, 0629T, 0630T, 0632T, 30468, 32408, 33741, 33745, 33995, 33997, 55880, 69705, and 69706

The following procedure codes have been removed from attachments A1 and A2 of this policy:

0228T, 0230T, 19324, 19366, 32405, 49220, 57112, 58293, 61870, 62163, 63180, 63182, 69605, 92992, 92993

The following procedure codes in attachments A1 and A2 of this policy have had narrative revisions:
11970, 11971, 19318, 19325, 19328, 19330, 19340, 19342, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29827, 29828, 33990 33991, 33992, 33993, 37619, 50740, 64455, 64479, 64483​

Revisions From 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.

Revisions From 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

12/30/2024
12/30/2024
11.00.10
Claim Payment Policy Bulletin
Commercial
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.