Multiple Surgeries
Multiple surgeries are separate procedures performed by a physician on the same patient at the same operative session or on the same day. Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. Intraoperative services, incidental surgeries or components of surgeries will not be separately reimbursed.
Reimbursement is based on the following guidelines for multiple surgical procedures:
- 100% of the allowance for the highest valued procedure.
- 50% of the allowance for the second through the fifth highest valued procedures.
When more than five procedures are performed, reimbursement for the sixth and subsequent procedures will be reviewed on an individual consideration basis. Operative notes should be submitted with the claim when five or more surgical procedures are performed during the same operative session.
The limiting charge is 115% of the reduced payment amount for each procedure.
Reporting Guidelines
Providers do not need to report modifier 51 on claims. The claims processing system has hard-coded logic to append the modifier to the correct procedure codes.
However, if you do report modifier 51, follow the guidelines below:
- Report the highest valued procedure.
- Report any additional surgical procedures with modifier 51.
Example
If you are billing for a repair of a rotator cuff (Code 23412), and a ligament release (code 23415), and a claviculectomy (code 23120), report the codes as follows:
- 23412
- 23415 51
- 23120 51
If surgeons of different specialties perform a different procedure (with specific CPT codes), multiple surgery rules do not apply. If one of the surgeons performs multiple procedures, the multiple surgery rules apply to that physician's services.
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