Friday, October 28, 2016

Payment Guide -Multiple and Bilateral Surgical Procedures Performed in the Same Operative Session


Selected bilateral eligible services may also be subject to multiple procedure reductions when billed alone or with other  multiple procedure reduction codes. When two or more procedure codes subject to reductions are performed on the same date of service and are subject to reduction as defined in the Federal register, only one of the procedure codes will be considered as the primary procedure, and all the remaining procedures will be considered secondary. The procedure with the highest CMS-based Relative Value Unit or contracted allowance, after the bilateral adjustment, as appropriate, will be considered the primary procedure.

Note: The bilateral procedure is not always the primary procedure. Assistant surgeon fees will be subject to multiple procedure reductions.


Idaho and Montana Examples

First bilateral procedure equals150 percent of the fee schedule allowance or your billed charge, whichever is less.

Second bilateral procedure equals 75 percent of the fee schedule allowance (150% reduced by half) or your billed charge, whichever is less.

Please note: If the bilateral procedures are billed on two separate lines on the claim, the reduction will be split evenly between both lines.

• When billing two bilateral procedures:

-- Primary bilateral = 150 percent of the fee schedule allowance for the procedure

-- Secondary bilateral = 75 percent of the fee schedule allowance for the procedure; 150 percent X 50 percent = 75 percent

• When billing a primary, non-bilateral procedure and a secondary bilateral procedure:

-- Primary procedure = 100 percent of the fee schedule allowance for the procedure

-- Secondary bilateral procedure = 75 percent of the fee schedule allowance for the procedure; 150 percent X 50 percent

= 75 percent

• When billing a primary bilateral procedure and a secondary procedure:

-- Primary bilateral = 150 percent of the fee schedule allowance for the procedure

-- Secondary procedure = 50 percent of the fee schedule allowance for the procedure


Procedure    Billed      Contract Allowed         Modifier           Considered  Allowed


31255-50 $4,000.00 $2,100.00 X 150% $3,150.00

31276-51 $1,100.00 $975.00 X 50% $487.50

31267-51 $1,100.00 $975.00 X 50% $487.50



For this example, the primary procedure is 31255- 50 and allowed at 150 percent of the fee schedule allowance or billed charges, whichever is less. All remaining procedures are allowed at 50 percent of the fee schedule allowance.



Procedure          Billed           Contract Allowed      Modifier          Considered Allowed


30140-51, 50 $1,200.00 $500.00 150% X 50% $375.00

30520 $2,950.00 $2,500.00 Primary @ 100% $2,500.00

31200-51 $975.00 $900.00 X 50% $ 450.00

For this example, the primary procedure is 30520 and allowed at 100 percent of the fee schedule allowance. The secondary procedure is 30140-50 and allowed at 150 percent X 50 percent resulting in a reimbursement of 75 percent of the fee schedule allowance. The third procedure, 31200, is allowed at 50 percent of the fee schedule allowance.


Oregon Examples

First bilateral procedure equals150 percent of the fee schedule allowance or your billed charge, whichever is less.

Second bilateral procedure equals 50 percent of the fee schedule allowance (25% X 2) or your billed charge, whichever is less.

Please note: If the bilateral procedures are billed on two separate lines on the claim, the reduction will be split evenly between both lines.

• When billing two bilateral procedures:

-- Primary bilateral = 150 percent of the fee schedule allowance for the procedure

-- Secondary bilateral = 25 percent of the fee schedule allowance for the procedure; 25 percent X 2 = 50 percent

• When billing a primary, non-bilateral procedure and a secondary bilateral procedure:

-- Primary procedure = 100 percent of the fee schedule allowance for the procedure

-- Secondary bilateral procedure = 75 percent of the fee schedule allowance for the procedure; 150 percent X 50 percent

= 75 percent

• When billing a primary bilateral procedure and a secondary procedure:

-- Primary bilateral = 150 percent of the fee schedule allowance for the procedure

-- Secondary procedure = 25 percent of the fee schedule allowance for the procedure


Procedure           Billed           Contract  Allowed               Modifier        Considered Allowed


31255-50 $4,000.00 $2,100.00 X 150% $3,150.00

31276-51 $1,100.00 $975.00 X 25% $243.75

31267-51 $1,100.00 $975.00 X 25% $243.75

For this example, the primary procedure is 31255- 50 and allowed at 150 percent of the fee schedule allowance or billed charges, whichever is less. All remaining procedures are allowed at 25 percent of the fee schedule allowance.


Procedure          Billed              Contract Allowed           Modifier            Considered Allowed


30140-51, 50 $1,200.00 $500.00 150% X 50% $375.00

30520 $2,950.00 $2,500.00 Primary @ 100% $2,500.00

29881-51 $975.00 $900.00 X 25% $ 225.00


For this example, the primary procedure is 30520 and allowed at 100 percent of the fee schedule allowance. The secondary procedure is 30140-50 and allowed at 150 percent X 50 percent resulting in a reimbursement of 75 percent of the fee schedule
allowance. The third procedure, 29881, is allowed at 25 percent of the fee schedule allowance.

No comments:

Post a Comment

Most read colonoscopy CPT codes