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 website:
- Select the year from the drop-down
- Under Type of Information, select 'Payment Policy Indicators'
- Identify the HCPCS search criteria
- Enter the procedure code(s) and select 'All Modifiers'
- Click 'Submit'
Refer to the column heading 'Mult Surg'
Multiple Surgery Indicator |
Explanation |
Example CPT Codes and Short Descriptions |
---|---|---|
0 |
No payment adjustment rules for multiple procedures apply.
|
17312: Mohs addl stage |
1 |
This indicator is not used. |
None |
2 |
Multiple procedure rules apply.
If the submitted charge is less than the fee schedule-based charge, reimbursement will be based on the submitted charge |
17311: Mohs, 1 stage, h/n/hf/g |
3 |
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 an endoscopic procedure is reported with only its base procedure, CGS will not make separate payment for the base endoscopy because payment for the base endoscopy is included in payment for the other endoscopy |
43239: Upper GI endoscopy w/ biopsy |
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 | CPT Code | Mult Surg Indicator | Submitted Amount | Fee Schedule Amount (participating, in OH) | Reimbursement Basis |
---|---|---|---|---|---|
01/15/21 | 17311 | 2 | $450.00 | $321.58 | Full fee schedule amount: $321.58 (subject to coinsurance and deductible) |
17312 | 0 | $250.00 | $170.92 | 100% of fee schedule amount: $170.92 (subject to coinsurance and deductible) | |
17313 | 2 | $375.00 | $288.35 | 50% of the fee schedule amount: $144.18 (subject to coinsurance and deductible) | |
17314 | 0 | $200.00 | $158.72 | 100% of fee schedule amount: $158.72 (subject to coinsurance and deductible) |
Example: inpatient hospital setting, 3 surgeries by the same surgeon on the same date
Date of Service | CPT Code | Mult Surg Indicator | Submitted Amount | Fee Schedule Amount (participating, in KY) | Reimbursement Basis |
---|---|---|---|---|---|
02/05/21 |
43622 |
2 |
$3000.00 |
$2050.81 |
Full fee schedule amount: $2050.81 (subject to coinsurance and deductible) |
44640 |
2 |
$1500.00 |
$1233.99 |
50% of the fee schedule amount: $617.00 (subject to coinsurance and deductible) |
|
44120 |
2 |
$500.00 |
$1081.85 |
50% of the fee schedule amount: $540.93; however, the lower submitted amount is paid: $500.00 (subject to coinsurance and deductible) |
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).