CurrentBlue Cross Blue Shield - MainePolicy C-21004

Multiple Surgery - Facility, Commercial Reimbursement Policy

Governs facility reimbursement when multiple procedures are performed in the same session or day; applies to commercial facility providers unless superseded by provider, state, or federal contracts or market-specific exemptions.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMultiple Surgery - Facility, Commercial Reimbursement Policy

Policy CodePolicy C-21004

Change TypeNo material change

Effective DateJan 1, 2022

Next Review Date

Key ActionReimburse only the primary (highest valued) procedure when multiple procedures are performed same day/session/place; do not append modifier 51 to facility claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

primary onlyPrimary procedure reimbursed

Modifier 51 not usedModifier 51 guidance

Maine exemptMaine market

NH exemptNew Hampshire market

WI 100/50/50Wisconsin schedule

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Multiple Surgery Facility Reimbursement Criteria

Multiple surgery facility reimbursement rules and market exemptions

Facility reimbursement follows multiple procedure reduction: only the primary/highest‑valued procedure is reimbursed at full rate; market exemptions apply.

Reimburse only the primary (highest valued) procedure when multiple procedures are performed on the same day, same session, and at the same place of treatment.

Do not append modifier 51 to facility claims.

Market exemptions

Maine market is not subject to this policy.
New Hampshire market is not subject to this policy.
Wisconsin reimburses surgeries using a 100%/50%/50% schedule: 100% of the fee schedule or contracted rate for the highest valued procedure; 50% for the secondary through 5th procedures; and 50% for the 6th and additional procedures.

A single surgical procedure submitted with multiple units is subject to multiple procedure reduction guidelines.

Modifier and Market Coding Notes

Modifier usage for facility claimsModifier

51	Modifier 51 should not be appended to facility claims; appropriate for professional claims only

Wisconsin surgical reimbursement schedule — key facts

Wisconsin schedule100% for the highest valued procedure; 50% for secondary through 5th procedures; 50% for the 6th and additional procedures.

Reimbursement basisTotal of 100% of the fee schedule or contracted/negotiated rate for the highest valued procedure; secondary and additional procedures paid at 50%.

Market applicabilityApplies to Wisconsin market per policy; Maine and New Hampshire are not subject to this policy (exemptions).

Billing and Reimbursement Actions for Providers

Billing Rule

Multiple procedure reimbursement rule — primary procedure only; do not use Modifier 51

Reimbursement is allowed only for the primary (highest valued) procedure when multiple procedures are performed the same day, same session, and at the same place of treatment. Modifier 51 should not be appended to facility claims; appending it may result in payment reduction or denial under this policy.

Only the highest‑valued procedure reimbursed at full rate when multiple procedures occur same day/session/place.
Do not append Modifier 51 to facility claims.

Definitions

Multiple Procedures / Modifier 51 — definition and modifier guidance

DefinitionMultiple Procedures: when multiple procedures (other than E/M, Physical Medicine and Rehabilitation services, or provision of supplies) are performed at the same session by the same individual.

Modifier 51 use (professional)Modifier 51 may be appended to additional procedure/service codes to identify additional procedures on professional claims.

Modifier 51 limitation (facility)Modifier 51 is only appropriate for professional claims and should not be appended to facility claims.

Multiple surgeries — definition

DefinitionMultiple surgeries: distinct surgical procedures performed by a provider on the same patient during the same operative session.

Reporting