When multiple surgeries or procedures are performed by a single physician or physicians in the same group practice on the same patient at the same operative session, reduction in reimbursement for secondary and subsequent procedures may occur.

Independent procedures (i.e., separate procedures) are procedures commonly performed with other major (primary) surgical procedures. When multiple independent procedures are performed, payment will be made only for the highest paying independent procedure.

Payment for independent procedure can be made when: 

• The sole surgical procedure performed; or
• The highest paying of multiple surgical procedures performed (any additional, covered non-independent procedures can be paid at 50%).

When a procedure or service is designated as a separate procedure it is carried out independently or considered to be unrelated or distinct from other procedures/services provided at that time. It may be reported by itself or in addition to other procedures/services by appending modifier 59, XE, XP, XS and XU to the specific separate procedure code. The modifier indicates that the procedure is not considered to be a component of another procedure, but is a distinct and independent procedure.

Independent procedures are eligible for payment under the following circumstances when reported with modifiers 59, XE, XP, XS or XU:

• Different operative session on same date of service; or
• Different site or separate area of injury; or
• Separate incision; or
• Different body orifices; or
• Bilateral procedures.

When multiple surgical procedures are performed as a result of trauma (i.e., emergency or life threatening situations) payment allowance for the highest paying procedure will be made at 100%, the next highest procedure will be made at 75% and the allowance for each additional surgical procedure thereafter will be made at 50%. These services are reported with the ST modifier. Guidelines with regard to independent procedures should be applied.

Hemodialysis and peritoneal dialysis should not be subjected to multiple surgical guidelines. The full allowance is made for all such charges.

NOTE: The allowances for certain surgical procedures performed as a result of trauma have been adjusted and, therefore, are not subject to the multiple surgery reduction. These surgical procedures are classified as add-on procedures and are identified by the phrase, list separately in addition to the code, for the primary procedure. Add-on codes are performed in addition to the primary service or procedure and must never be reported as a stand-alone code. Add-on services that are reported as a stand-alone procedure without the primary procedure will be denied as non-billable.
 
Multiple surgery reductions are not applied to surgical procedures performed as a result of trauma identified as modifier 51-exempt. 

Delaware Mandate

Effective January 1, 2000, the Delaware Insurance Department (DOI) adopted Regulation 1311 which sets standards of payment for multiple surgical procedures.  The stated purpose of this regulation is to ensure that health insurers provide proper payment to healthcare providers when more than one surgical service is performed on the same patient, by the same physician, on the same day.

This regulation applies to individual and group health benefit policies subject to Delaware law and to those self-insured accounts that elect to follow this Delaware mandate.

DOI Regulation 1311 requires when more than one surgical service is performed:

• on the same patient,
• by the same physician and
• on the same day,

Insurers shall make payment to the providers as follows:

(1) One hundred percent (100%) of the fee schedule for the procedure which has the highest regular fee schedule amount; and

(2) For each additional procedure, performed through the same incision or separate incisions, as set forth in the National Correct Coding Manual established by Administar Federal under contract with the Health Care Financing Administration, not less than fifty percent (50%) of the fee schedule amount.

Multiple Surgical Procedures is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.