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:
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:
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:
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
|
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 |
|
|
|
|
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.
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.
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:
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:
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.