Reimbursement shall be made for all medically necessary surgical procedures when more than one (1) procedure is performed at a single operative session. Each procedure performed shall be identified by use of the appropriate five-digit CPT®
• The primary, or most clinically significant procedure, shall be reported first without appending modifier 51. code and listed separately.
• Each additional surgical procedure code shall be listed separately and reported by appending modifier 51.
Multiple Surgical Procedure Reimbursement Amount
To find the reimbursable amount on any additional surgical procedure(s), identify the following four (4) values:
1. The reimbursable amount of the billed primary procedure code pursuant to the policy in this Manual, and (100% would be paid)
2. 50% of the allowed billed charge for the additional surgical procedure code,
3. The MRA of the billed additional surgical procedure code from the Fee Schedule in Section V, if any, and
4. The contracted reimbursement amount, if applicable.
If there is a contracted reimbursement amount, reimburse the contracted amount.
Otherwise, reimbursement is the lesser value of either item 2 or item3, not to exceed the value identified in item 1.
No comments:
Post a Comment