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Pricing Multiple Surgical Procedures (Non-Endoscopic)

Background

When multiple surgical procedures are performed on the same date, special pricing methodology is used to determine Medicare reimbursement.

Multiple Surgery Indicator Example CPT Codes Explanation
0 17312: Mohs addl stage

49568: Hernia repair w/ mesh

58110: Biopsy done with colposcopy add-on
No payment adjustment rules for multiple procedures apply.
  • Procedures with multiple surgery indicator 0 are often 'add-on' procedures
  • Do not submit CPT modifier 51. Submitting this modifier will cause the service to be rejected as a billing error.
1 None This indicator is not used.
2 17311: Mohs, 1 stage, h/n/hf/g

47562: Laparoscopic cholecystectomy

52601: Prostatectomy (TURP)

58548: Laparoscopic radical hysterectomy
Multiple procedure rules apply.
  • If a procedure is reported on the same day as another procedure that has a multiple surgery indicator of 2 or 3, the procedures are ranked by fee schedule amount from highest to lowest
  • Reimbursement for the procedure with the highest fee schedule amount is based on 100% of the fee schedule
  • Reimbursement for each additional procedure is based on 50% of the fee schedule amount
  • If the submitted charge is less than the fee schedule-based charge, reimbursement will be based on the submitted charge
3 43239: Upper GI endoscopy w/ biopsy

45380: Colonoscopy and biopsy
Special rules for multiple endoscopic procedures apply if the procedure is submitted with another endoscopy in the same family (e.g., another endoscopy that has the same base procedure).
  • If multiple endoscopies are reported on the same day as other non-endoscopic surgical procedures, the multiple endoscopy rules are applied before other multiple procedure reductions
  • If an endoscopic procedure is reported with only its base procedure, Palmetto GBA will not make separate payment for the base endoscopy because payment for the base endoscopy is included in payment for the other endoscopy

Calculating Reimbursement for Multiple Surgical Procedures: Summary

Example: outpatient hospital setting, 4 Mohs procedures by the same surgeon on the same date

Date of Service CPT Code Mult Surg Indicator Submitted Amount Fee Schedule Amount (participating, in WV) Reimbursement Basis
01/15/11 17311 2 $450.00 $382.32 Full fee schedule amount ($382.32) (subject to coinsurance and deductible)
  17312 0 $250.00 $202.95 100% of fee schedule amount (subject to coinsurance and deductible)
  17313 2 $375.00 $343.03 50% of the fee schedule amount ($171.52) (subject to coinsurance and deductible)
  17314 0 $200.00 $188.22 100% of fee schedule amount ($188.22) (subject to coinsurance and deductible)

Example: inpatient hospital setting, 3 surgeries by the same surgeon on the same date

Date of Service CPT Code Mult Surg Indicator Submitted Amount Fee Schedule Amount (participating, in OH) Reimbursement Basis
02/05/11 43622 2 $3000.00 $2309.03 Full fee schedule amount ($2309.03) (subject to coinsurance and deductible)
  44640 2 $1500.00 $1407.95 50% of the fee schedule amount ($703.98) (subject to coinsurance and deductible)
  44120 2 $500.00 $1223.02 50% of the fee schedule amount = $611.51; however, the lower submitted amount is paid (subject to coinsurance and deductible)

Reference: Complete definitions of multiple surgery indicators are available in CMS Pub. 100-04, chapter 23 (PDF, 1.9 MB), in the Addendum following section 90 (field 21 of MPFSDB layout).


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