HIGHMARK COMMERCIAL MEDICAL POLICY - DELAWARE

 
 

Medical Policy:
S-100-011
Topic:
Multiple Surgical Procedures
Section:
Surgery
Effective Date:
January 1, 2020
Issued Date:
January 1, 2020
Last Revision Date:
November 2019
Annual Review:
November 2019
 
 

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.

Policy Position

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.

Integumentary

11755

19100

 

 

 

 

 

 

Musculoskeletal

20100

20101

20102

20103

20500

20650

20670

21070

21100

21280

21610

21750

24006

24149

24340

25230

25250

26185

26500

26502

27000

27005

27006

27090

27140

27161

27306

27605

27606

27685

28230

28250

28260

29800

29805

29830

29840

29860

29870

29875

29884

 

 

Respiratory

31231

31505

31600

31601

31622

31720

31725

32220

32225

32310

32551

32601

32604

32606

 

 

Cardiovascular

33140

33210

33211

33800

36410

36800

36810

36815

36821

36825

36830

36831

36832

36833

36835

36860

36861

37780

92961

 

 


Hemic Lymphatic

38562

38564

38760

38765

38770

38780

 


Digestive

42870

43191

43197

43200

43235

43260

43653

43830

43848

44005

44130

44180

44300

44312

44314

44316

44322

44340

44345

44346

44360

44376

44380

44385

44388

44680

44820

44850

45300

45330

45378

45900

45905

45910

45915

46040

46080

46220

46600

46940

46942

47460

47480

47552

47900

49000

49010

49250

49255

49320

49400

49423

49424

49570

 

 


Urinary

50100

50340

50600

50650

50900

51045

51520

51525

51570

51880

52000

52500

53000

53010

53020

53025

53080

53230

53235

53520

 

 

Male Genital

54000

54001

54100

54500

54505

54620

54660

55200

55250

55500

55520

55530

 

 

 

Female Genital

56605

56606

56810

57020

57100

57180

57268

57270

57415

57500

57530

57800

58555

58660

58700

58720

58800

58805

58900

 

 

 

 

Maternity

59200

 

 

 

 

 

 

                                          

Endocrine

60520

60521

60522

60540

60545

 

 

             

Nervous System

61050

 

 

 

 

 

 

 

Eye

65125

65800

65810

65815

65860

65865

65870

65875

65880

66020

66030

66500

66505

66625

66630

66635

66682

66825

67025

67028

67250

67255

67343

67500

67715

68360

68770

 

 

Ear

69310

69670

69700

 

 

 

 




Related Policies

Refer to Highmark Reimbursement Policy Bulletin RP-009, Modifiers 25, 59, XE, XP, XS and XU for additional information on reimbursement coverage.

Refer to Highmark Reimbursement Policy Bulletin RP-014, Multiple Surgical Procedures for additional information on reimbursement coverage.

 


Place of Service: Inpatient/Outpatient

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.



The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.