When multiple or bilateral surgical procedures are performed during the same operative session, by the same physician or his associate, payment will be made at 100% of the allowance for the highest paying or primary procedure, and 50% of the allowance for each secondary procedure. Individual consideration should be given to multiple surgical procedures performed by a physician and his associate when the surgical procedures warrant physicians of different specialties. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.

NOTE:

The allowances for certain surgical procedures have already been adjusted and, therefore, are not subject to the multiple surgery reduction. These surgical procedures are classified as add-on procedures and most are identified by the phrase "List separately in addition to the code for the primary procedure."

 

Multiple surgery reductions are not applied to those surgical procedures identified as "modifier 51-exempt." (See Appendix E of the AMA's CPT manual.) 

The independent procedures (i.e., separate procedures) listed on the Procedure Code Attachment below are those procedures most commonly performed with other more major (primary) surgical procedures. When multiple independent procedures are performed, payment will be made only for the highest paying independent procedure.

Payment for an independent procedure can be made when it is:

• the sole surgical procedure performed, or
• the highest paying of multiple surgical procedures performed (any additional, covered nonindependent procedures can be paid at 50%).

• different operative session on same date of service
• different site or separate area of injury
• separate incision
• different body orifices
• bilateral procedures

When multiple surgical procedures are performed as a result of trauma (i.e., emergency, life, or member threatening situations), payment will be made at 100% of the allowance for the highest paying procedure, 75% of the allowance for the next highest procedure and 50% of the allowance for each additional surgical procedure thereafter. These services should be 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 should be made for all such charges.

Coverage for Multiple Surgical Procedures is determined according to individual or group customer benefits.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.