Pricing Multiple Surgical Procedures (Non-Endoscopic)
When multiple surgical procedures are performed on the same date, special pricing methodology is used to determine Medicare reimbursement.
- Surgical procedures are identified in the Medicare Physician Fee Schedule
Database (MPFSDB) by certain 'multiple surgery indicators.' To access
the MPFSDB, refer to the CMS
- Under Type of Information, select Payment Policy Indicators
- Select 'Next'
- Enter the procedure code and select 'All Modifiers'
- Refer to the column heading 'Mult Surg'
- It is not necessary to submit multiple surgical procedures with CPT modifier 51. Palmetto GBA will add or remove this modifier when processing claims according to multiple surgery pricing guidelines.
|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.
|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.
|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).
Calculating Reimbursement for Multiple Surgical Procedures: Summary
- Identify all codes with multiple surgery indicator 2. Arrange the codes from highest to lowest fee schedule amount.
- Reimbursement for the code with the highest fee schedule amount will be based on 100 percent of the fee schedule amount (unless the billed amount is lower)
- Reimbursement for the additional procedures will be based on 50 percent of the fee schedule amount (unless the billed amount is lower)
- Codes with multiple surgery indicator 0 are not reduced
- Codes with multiple surgery indicator 3 are subject to endoscopic pricing rules (these pricing rules are the topic of a separate article)
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).