CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP015

Multiple Surgical Procedures - Professional Provider Services

Governs reimbursement and coding rules for professional providers submitting claims for multiple surgical procedures performed by the same provider on the same date and in the same operative session; applies to in-network and out-of-network professional surgical and medical services for BCBS Oklahoma members.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyMultiple Surgical Procedures - Professional Provider Services

Policy CodePolicy CPCP015

Change TypeNo material change

Effective DateJun 24, 2022

Next Review DateN/A

Key ActionBCBS OK may request supporting documentation and providers should submit additional documentation upon request to avoid claim denial or reassignment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%primary procedure eligibility

50%secondary/subsequent eligibility

1units per surgical line

4required conditions

Multiple Surgical Procedure Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyMultiple Surgical Procedures - Professional Provider Services

Policy CodePolicy CPCP015

Change TypeNo material change

Effective DateJun 24, 2022

Next Review DateN/A

Key ActionBCBS OK may request supporting documentation and providers should submit additional documentation upon request to avoid claim denial or reassignment.

SourceLink

On This Page

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ALL of the following

ALL of the following
- On the same date of service.
- Within the same operative session.
- Performed by the same provider.
- At the same place of treatment.

ALL of the following

Primary procedure: eligible at 100% of the fee schedule or billed amount, whichever is less; the primary procedure is the service line with the highest total allowable.
Secondary and subsequent procedures: eligible at 50% of the fee schedule or billed amount, whichever is less.

ALL of the following

All surgical services (multiple and/or bilateral) rendered by the same performing provider for the same member and date of service in the same setting should be submitted on one claim.
Surgical procedures should be submitted with one (1) unit. If the same surgical service was performed more than once and the procedure is not eligible for modifier 50, bill the procedure code on a separate line on the claim with one (1) unit.
Modifier 50 should only be reported on one line with one unit of service when applicable.

ANY of the following

Add-on codes are excluded from multiple surgical pricing reductions.
Codes exempt from Modifier-51 are excluded from multiple surgery reductions but an exempt code may be considered the primary procedure if it has the highest allowable.
Multiple surgical pricing reductions may also apply to bilateral surgical procedures as described under policy.

ALL of the following

The Plan reserves the right to request supporting documentation and may review claims on a case-by-case basis.
Claims that do not adhere to coding and billing guidelines may be denied or reassigned; providers should submit documentation upon request and follow the Plan's billing policies.

Coding, Modifiers, and Allowances

Modifiers referencedModifier

Modifier 51	May be appended for multiple procedures but not required; some codes exempt from Modifier-51 are excluded from multiple surgery reductions.
Modifier 50	Used for bilateral procedures; should be reported on one line with one unit.

Required code sets and guidelinesmixed

CPT, HCPCS, ICD-10, NDC, DRG

Standard HIPAA-approved code sets and coding guidelines expected for claim submission.

Primary procedure allowance

AllowancePrimary Procedure: 100% of the fee schedule or billed amount, whichever is less.

ApplicationApplies when two or more surgical procedures are performed on the same date of service by the same professional provider.

SubmissionAll surgical services by the same performing provider for the same member and date of service in the same setting should be submitted on one claim.

Secondary/subsequent procedure allowance

AllowanceSecondary and Subsequent Procedures: 50% of the fee schedule or billed amount, whichever is less.

TriggerApplies when additional surgical procedures are performed by the same professional provider on the same date and in the same operative session.

Billing GuidanceSurgical procedures should be submitted with one (1) unit; if the same service performed more than once and not eligible for modifier 50, bill on separate lines with one unit each.

Documentation and Review Expectations

Documentation Required

Provide supporting documentation upon request — failure may lead to denial or reassignment

BCBS Oklahoma may request supporting documentation and may review claims on a case-by-case basis; providers are urged to submit additional documentation upon request. Claims that do not adhere to coding and billing guidelines may result in denial or reassigned payment.

Providers are responsible for submission of accurate documentation of services performed and should submit claims using valid HIPAA-approved code sets and industry coding guidelines.
Upon request, the provider is urged to submit any additional documentation to support the claim.

Definitions

Primary Procedure — definition and eligibility

DefinitionPrimary Procedure: The service line with the highest total allowable.

EligibilityPaid at 100% of the fee schedule or billed amount, whichever is less.

ConditionsMust be performed on the same date of service, within the same operative session, by the same provider, and at the same place of treatment to be considered with multiple procedures.

Secondary/Subsequent Procedure — definition and eligibility

DefinitionSecondary/Subsequent Procedure: Additional surgical procedures performed by the same provider in the same operative session.

EligibilityPaid at 50% of the fee schedule or billed amount, whichever is less.

Billing NoteAll such services should be submitted on one claim; surgical procedures should be submitted with one (1) unit unless the same procedure repeats and is not eligible for modifier 50.

Bilateral Procedure — definition and applicability

DefinitionBilateral Procedure: Surgical procedures performed on both sides of the body during the same surgical session or on the same day.

ApplicabilityMultiple surgical pricing reductions may apply to bilateral procedures.

Modifier GuidanceModifier 50 should be reported on one line with one unit when applicable; if not reported, bill procedures per guidance on separate lines as required.