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
||17312: Mohs addl stage
49568: Hernia repair w/ mesh
58110: Biopsy done with colposcopy add-on
|No payment adjustment rules for multiple procedures apply.
- Procedures with multiple surgery indicator 0 are often 'add-on'
- Do not submit CPT modifier 51. Submitting this modifier will
cause the service to be rejected as a billing error.
||This indicator is not used.
||17311: Mohs, 1 stage, h/n/hf/g
47562: Laparoscopic cholecystectomy
52601: Prostatectomy (TURP)
58548: Laparoscopic radical hysterectomy
|Multiple procedure rules apply.
- If a procedure is reported on the same day as another procedure
that has a multiple surgery indicator of 2 or 3, the procedures
are ranked by fee schedule amount from highest to lowest
- Reimbursement for the procedure with the highest fee schedule
amount is based on 100% of the fee schedule
- Reimbursement for each additional procedure is based on 50%
of the fee schedule amount
- If the submitted charge is less than the fee schedule-based
charge, reimbursement will be based on the submitted charge
||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).
- If multiple endoscopies are reported on the same day as other
non-endoscopic surgical procedures, the multiple endoscopy rules
are applied before other multiple procedure reductions
- If an endoscopic procedure is reported with only its base procedure,
Palmetto GBA will not make separate payment for the base endoscopy
because payment for the base endoscopy is included in payment
for the other endoscopy
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
||Mult Surg Indicator
||Fee Schedule Amount (participating, in WV)
||Full fee schedule amount ($382.32) (subject to coinsurance and
||100% of fee schedule amount (subject to coinsurance and deductible)
||50% of the fee schedule amount ($171.52) (subject to coinsurance
||100% of fee schedule amount ($188.22) (subject to coinsurance and
Example: inpatient hospital setting, 3 surgeries by the same surgeon
on the same date
|Date of Service
||Mult Surg Indicator
||Fee Schedule Amount (participating, in OH)
||Full fee schedule amount ($2309.03) (subject to coinsurance and
||50% of the fee schedule amount ($703.98) (subject to coinsurance
||50% of the fee schedule amount = $611.51; however, the
lower submitted amount is paid (subject to coinsurance
Reference: Complete definitions of multiple surgery indicators
are available in CMS
Pub. 100-04, chapter 23, in the Addendum following section 90 (field 21 of MPFSDB layout).