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Provider Manual

Multiple Surgeries

Last Updated on August 28, 2018

Reimbursement will be made as follows:

  • 100 percent of the maximum allowable fee for the primary procedure listed 
  • 50 percent for the second through the fifth procedure 
  • Each procedure after the fifth procedure will be considered on a case-by-case basis 

Endoscopic procedures:

  • Payment is made in full for the highest valued procedure performed plus the difference between the next highest procedure and the base endoscopy. 
  • When two unrelated endoscopies are performed, the multiple surgery rules apply. The second procedure is billed with the 51 modifier. 

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 current CPT references, bilateral procedures that are performed at the same operative session should be identified by the appropriate five-digit code and modifier 50. The procedure billed will be reimbursed at 150 percent of the fee schedule amount.

Surgery Assistants

Assistants at surgery are covered when an 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:

  • M.D. assistant, 20 percent of the fee schedule amount for the surgery 
  • P.A. assistant, 16 percent of the fee schedule amount for the surgery 
  • N.P. assistant, 16 percent of the fee schedule amount for the surgery 

The multiple surgery reduction for subsequent procedures on the same day does apply to reimbursement for the assistant at surgery.

Reference the Medicare Physician Fee Schedule Database for specific CPT information at: www.cms.gov/apps/physician-fee-schedule

Surgical Trays

The cost of surgical trays is generally included in the cost of the procedure being performed. Security Health Plan will only reimburse for supplies that are excessive. Supporting documentation will be required before these will be considered for payment. Do not report supplies that are customarily included in surgical packages, such as gauze, sponges, applicators or steri-strips.