MA PPO

Multiple Surgery Payment Reduction
MA11.032f


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

CPT Procedure Code Number(s)
REFER TO:
  • Attachment A1 or A2 for Current Procedural Terminology (CPT) codes to which multiple surgical reduction guidelines apply.




ICD - 10 Procedure Code Number(s)
N/A

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



Policy History

3/30/2020
3/30/2020
MA11.032
Claim Payment Policy Bulletin
Medicare Advantage
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Yes