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Utilization Management
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Benefit Information
Surgery Information
Last Updated on January 24, 2019
Multiple Surgery
Reimbursement will be made as follows:
- 100% of the maximum allowance fee for the primary procedure listed.
- 50% for the second through the fifth procedure.
- Each procedure after the fifth procedure will be considered on a case-by-case basis.
Exceptions to multiple procedures for a charge reduction are CPT codes, which by definition are always done and billed in conjunction with another procedure. These include codes described as “additional segments” or “second lesion.”
Bilateral Procedures
Unless otherwise identified in the listings in the CPT book, bilateral procedures that are performed at the same operative session should be identified by the appropriate five-digit code and modifier 50.
Bilateral procedures are paid based on the Medicaid Fee Schedule.
Assistants at Surgery
Assistants at surgery are covered when the assistant is considered medically necessary and appropriate. Criteria considered include the need for the expertise of another surgeon in a complicated case for decision-making or surgical involvement.
Reimbursement rate is based on the Medical Fee Schedule.
The multiple surgery reduction for subsequent procedures on the same day does apply to reimbursement for the assistant at surgery. When billing an assistant at surgery, use modifier 80 for a physician and modifier AS for a physician’s assistant or nurse practitioner.