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MA PPO Host - Claim Payment Policy Bulletin

Multiple Surgery Payment Reduction
MA11.032h

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.

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 noncovered 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 procedures 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

When a professional provider performs more than one surgical procedure on the same individual, during the same operative session, or on the same date of service, 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

    Policy History

    Revisions From MA11.032h:
    12/30/2024
    This 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 â€‹MA11.032g:
    01/01/2024​
    		​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
    ​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 MA11.032f:
    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 MA11.032e:
    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


    Revisions From MA11.032d:
    01/01/2017This policy has been identified for the CPT code update.

    The following CPT codes have been added to this policy, effective 01/01/2017:

    0446T, 0447T, 0448T, 0449T, 0450T, 0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T, 0460T, 0461T, 0465T, 0466T, 0467T, 0468T, 22853, 22854, 22859, 22867, 22868, 22869, 22870, 27197, 27198, 28291, 28295, 31551, 31552, 31553, 31554, 31572, 31573, 31574, 31591, 31592, 33340, 33390, 33391, 36456, 36473, 36474, 36901, 36902, 36903, 36904, 36905, 36906, 36907, 36908, 36909, 37246, 37247, 37248, 37249, 43284, 43285, 58674, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62380, 93590, 93591, 93592, D6081

    The following CPT codes has been deleted from this policy, effective 12/31/2016:

    0019T, 0169T, 0171T, 0281T, 0282T, 0283T, 0284T, 0288T, 0336T, 0392T, 0393T, 11752, 21495, 22305, 27193, 27194, 28290, 28293, 28294, 31582, 31588, 33400, 33401, 33403, 35450, 35452, 35458, 35460, 35471, 35472, 35475, 35476, 36147, 36870, 62310, 62311, 62318, 62319, 75791, 93965


    The following CPT codes have been revised in this policy, effective 01/01/2017:

    FROM:

    0274t percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, ct), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic

    0275t percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, ct), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar

    0409t insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only

    0418t interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable cardiac contractility modulation system

    0419t destruction neurofibromata, extensive, (cutaneous, dermal extending into subcutaneous); face, head and neck, greater than 50 neurofibromata

    0420t destruction neurofibromata, extensive, (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromata

    11603 excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm

    11623 excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm

    19298 placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance

    20240 biopsy, bone, open; superficial (eg, ilium, sternum, spinous process, ribs, trochanter of femur)

    20245 biopsy, bone, open; deep (eg, humerus, ischium, femur)

    28289 hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint

    28292 correction, hallux valgus (bunion), with or without sesamoidectomy; keller, mcbride, or mayo type procedure

    28296 correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy (eg, mitchell, chevron, or concentric type procedures)

    28297 correction, hallux valgus (bunion), with or without sesamoidectomy; lapidus type procedure

    28298 correction, hallux valgus (bunion), with or without sesamoidectomy; by phalanx osteotomy

    28299 correction, hallux valgus (bunion), with or without sesamoidectomy; by double osteotomy

    31575 laryngoscopy, flexible fiberoptic; diagnostic

    31576 laryngoscopy, flexible fiberoptic; with biopsy

    31577 laryngoscopy, flexible fiberoptic; with removal of foreign body

    31578 laryngoscopy, flexible fiberoptic; with removal of lesion

    31579 laryngoscopy, flexible or rigid fiberoptic, with stroboscopy

    31580 laryngoplasty; for laryngeal web, two stage, with keel insertion and removal

    31584 laryngoplasty; with open reduction of fracture

    31587 laryngoplasty, cricoid split

    33405 replacement, aortic valve, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve

    33406 replacement, aortic valve, with cardiopulmonary bypass; with allograft valve (freehand)

    33410 replacement, aortic valve, with cardiopulmonary bypass; with stentless tissue valve

    37192 repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed

    37650 ligation of femoral vein

    37660 ligation of common iliac vein

    38760 inguinofemoral lymphadenectomy, superficial, including cloquets node (separate procedure)

    47538 placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation, each stent; existing access

    47539 placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation, each stent; new access, with placement of separate biliary drainage catheter

    47540 placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation, each stent; new access, with placement of separate biliary drainage catheter (eg, external or internal-external)

    52500 transurethral resection of bladder neck (separate procedure)

    62287 decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar

    66740 ciliary body destruction; cyclodialysis

    67101 repair of retinal detachment, 1 or more sessions; cryotherapy or diathermy, including drainage of subretinal fluid, when performed

    67105 repair of retinal detachment, 1 or more sessions; photocoagulation, including drainage of subretinal fluid, when performed

    92235 fluorescein angiography (includes multiframe imaging) with interpretation and report

    92240 indocyanine-green angiography (includes multiframe imaging) with interpretation and report


    TO:

    0274T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic

    0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar

    0409T Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only

    0418T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac contractility modulation system

    0419T Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); face, head and neck, greater than 50 neurofibromas

    0420T Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromas

    11603 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm

    11623 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm

    19298 Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance

    20240 Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx)

    20245 Biopsy, bone, open; deep (eg, humeral shaft, ischium, femoral shaft)

    28289 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant

    28292 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method

    28296 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method

    28297 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method

    28298 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal phalanx osteotomy, any method

    28299 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double osteotomy, any method
    31575 Laryngoscopy, flexible; diagnostic

    31576 Laryngoscopy, flexible; with biopsy(ies)

    31577 Laryngoscopy, flexible; with removal of foreign body(s)

    31578 Laryngoscopy, flexible; with removal of lesion(s), non-laser

    31579 Laryngoscopy, flexible or rigid telescopic, with stroboscopy

    31580 Laryngoplasty; for laryngeal web, with indwelling keel or stent insertion

    31584 Laryngoplasty; with open reduction and fixation of (eg, plating) of fracture, includes tracheostomy, if performed

    31587 Laryngoplasty, cricoid split, without graft placement

    33405 Replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve

    33406 Replacement, aortic valve, open, with cardiopulmonary bypass; with allograft valve (freehand)

    33410 Replacement, aortic valve, open, with cardiopulmonary bypass; with stentless tissue valve

    37192 Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed

    37650 Ligation of femoral vein

    37660 Ligation of common iliac vein

    38760 Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure)

    47538 Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation; existing access

    47539 Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation; new access, without placement of separate biliary drainage catheter

    47540 Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation; new access, with placement of separate biliary drainage catheter (eg, external or internal-external)

    52500 Transurethral resection of bladder neck (separate procedure)

    62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar

    66740 Ciliary body destruction; cyclodialysis

    67101 Repair of retinal detachment, including drainage of subretinal fluid when performed; cryotherapy

    67105 Repair of retinal detachment, including drainage of subretinal fluid when performed; photocoagulation

    92235 Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral

    92240 Indocyanine-green angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral

    Revisions From â€‹MA11.032c:
    05/20/2016
    		This policy has been identified for CPT code update, effective 01/01/2016. 

    The following CPT codes have been added to this policy:

    10035,31652,31653,33477,39401,39402,43210,47531,47532,47533,47534,47535,47536, 47537,47538,47539,47540,47541,49185,50430,50431,50432,50433,50434,50435,50693, 50694,50695,54437,54438,61645,61650,64461,64463,65785,69209,0402T,0404T,0406T, 0407T,0408T,0409T,0410T,0411T,0412T,0413T,0414T,0415T,0416T,0417T,0418T,0419T, 0420T, 0421T,0424T,0425T,0426T,0427T,0428T,0429T,0430T,0431T,0432T,0433T


    The following CPT codes have been deleted to this policy:
    21805,37202,39400,47136,47500,47505,47510,47511,47525,47530,47560,47561,
    47630,50392,50393,50394,50398,64412,0099T,0123T,0262T,G6018,G6019,G6020,
    G6021,G6022,G6023,G6024,G6025,G6027,G6028

    Revisions From     MA11.032b:
    07/01/2015This policy has been identified for CPT code update, effective 07/01/2015.

    The following CPT codes been added to this policy: 0392T, 0393T

    Revisions From MA11.032a:
    03/02/2015Policy # MA11.032 has been identified for the Annual CPT/HCPCS code updates and will be reissued as MA11.032a

    The following CPT codes have been deleted to the policy:
    21800, 21810, 22520, 22521, 22523, 22524, 29020, 29025, 29715, 33332, 33472, 33960, 36469, 36822, 42508, 43350, 44383, 44393, 44397, 45339, 45345, 45355, 45383, 45387, 61334, 61440, 61470, 61490, 61542, 61875, 62116, 64752, 64761, 64870, 66165, 69400, 69401, 69405, 0245T, 0246T, 0247T, 0248T, 0319T, 0320T, 0321T, 0322T, 0323T, 0324T, 0325T, 0326T, 0327T, 0328T, 0334T, 0343T, 0344T

    The following CPT codes have been revised to the policy:
    0075T, 0191T, 0200T, 0201T, 0253T, 20600, 20605, 20610, 20982, 22856, 27280, 27370, 33215, 33216, 33217, 33218, 33220, 33223, 33224, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 37215, 37216, 37217, 43194, 43197, 43215, 43216, 43247, 43250, 44360, 44363, 44380, 44385, 44386, 44388, 44390, 44391, 44392, 44799, 45330, 45332, 45333, 45334, 45337, 45340, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45391, 45392, 46600, 61055, 62284, 66180, 66185, 67399, 93642, D7285,
    D7286

    The following CPT codes have been added to the policy:
    0375T, 0377T, 0387T, 0388T, 20604, 20606, 20611, 20983, 21811, 21812, 21813, 22510, 22511, 22513, 22514, 27279, 33270, 33271, 33272, 33273, 33418, 33946, 33947, 33948, 33949, 33951, 33952, 33953, 33954, 33955, 33956, 33957, 33958, 33959, 33962, 33963, 33964, 33965, 33966, 33969, 33984, 33985, 33986, 33988, 33989, 37218, 43180, 44381, 44384, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45346, 45347, 45349, 45350, 45388, 45389, 45390, 45393, 45398, 45399, 46601, 46607, 47383, 52441, 62302, 62303, 62304, 62305, 64486, 64487, 64488, 64489, 66179, 66184, 93644, 97607, 97608, G0276, G6018, G6019, G6020, G6021, G6022, G6023, G6024, G6025, G6027, G6028

    Revisions From MA11.032:
    01/01/2015This is a new policy.
    12/30/2024
    12/30/2024
    MA11.032
    Claim Payment Policy Bulletin
    Medicare Advantage
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