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Regence BCBSO Reimbursement Policy

Modifier -51 and Multiple Procedure Logic

Topic: Modifier -51 and Multiple Procedure Logic Date of Origin: April 1997
Section: Modifiers Policy No: 101
Last Reviewed: October 2013 Last Revised: October 2013
Approved: October 2013  

Description

This policy does not apply to facilities (hospitals, surgery centers, kidney centers, etc…)

Modifier -51
When multiple procedures are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or services(s) shall be identified by appending modifier 51 to the additional procedure or service codes(s).

Modifier 51 should not be appended to designated “add-on” codes. 

Multiple Service Reduction
Centers for Medicare and Medicaid (CMS) Multiple Procedure Indicators (MULT PROC) are found in the CMS National Physician Fee Schedule Relative Value File.  Values which are currently in the CMS file are:

Value
Description
0
No payment adjustment rules for multiple procedures apply.

2

Standard payment adjustment rules for multiple procedure apply.
3
Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family.
4
Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imagining procedure in the same family.
5 Special reduction rule for the practice expense component for certain therapy services.
6 Special reduction rule for the technical component (TC) of cardiovascular services.
7 Special reduction rule for the technical component (TC) of ophthalmology services.
9
Concept does not apply.

Policy Statement

NOTE: This policy has been revised. The revised policy will be effective September 1, 2014. To view the revised policy, click here.

Our health plan will process and separately reimburse those codes listed in the AMA CPT book as modifier 51 exempt CPT Codes without reducing payment under our health plan’s Multiple Procedure Logic, provided that the AMA CPT book provides that such services are appropriately reported together.

We will process and separately reimburse codes listed in the AMA CPT book as add-on billing codes without reducing payment under our health plan’s Multiple Procedure Logic; provided that the AMA CPT book provides that such add-on CPT Codes are appropriately billed with proper primary procedure codes.

Our health plan follows the American Medical Association (AMA) CPT guidelines and the CMS Multiple Procedure Indicators in determining which codes are eligible for MSR.  We consider codes with CMS Multiple Procedure Indicators of 2 and 3 eligible for MSR. We consider codes which AMA CPT flags as “Modifier 51 Exempt” or as “Add-On” not eligible for MSR. When AMA and CMS conflict, AMA guidelines take precedence.

Our health plan considers codes with CMS Multiple Procedure Indicator of 0 eligible for MSR in once instance: when CMS assigns a MULT PROC rule of 0 to a –TC modified code, but a MULT PROC rule of 2 to other modified versions of the same code. In these instances, all 3 codes (no modifier, modifier -26 and modifier –TC) will be considered eligible for MSR.

For instance:

93505 Biopsy of heart lining
          93505-00 has an MULT PROC rule of 2
          93505-TC has a MULT PROC rule of 0
          93505-26 has a MULT PROC rule of 2
All three codes will be eligible for a multiple procedure discount.

Our health plan applies multiple service reduction (MSR) according to the following guidelines:

Multiple procedures that are eligible for MSR and are performed at the same session by the same provider  are  ranked by fee schedule amount multiplied by the administrative percent associated with any appropriate pricing modifier(s) (such as, but not limited to  22, 50, 54, 55, 56, 62, 63, 78, 80, 81, 82, AS) appended. The code with the highest calculated fee (after the modifier % adjustment) will be reimbursed at 100% of the calculated fee. The code with the second highest calculated fee (after the modifier % adjustment) will be reimbursed at 50% of the calculated fee.  All other codes subject to MSR will be reimbursed at 25% of the calculated fee.

In the event that bilateral procedures are performed at the same session as other surgical procedure(s) eligible for MSR, follow the billing guidelines outlined below to ensure accurate reimbursement:

  1. If the bilateral procedure is determined to be primary because it has the highest allowed after the 150% bilateral adjustment, it should be submitted with modifier 50 only.  Do not submit with modifier 51.
  2. If the bilateral procedure is ranked as secondary after the 150% bilateral adjustment, it should be submitted with modifier 50 and 51.

References

  1. Current Procedural Terminology (CPT), American Medical Association.

Cross References

Modifier 50; Bilateral Procedure

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.

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