CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP015

Multiple Surgical Procedures-Professional Provider

Governs professional provider reimbursement when multiple or bilateral surgical procedures are performed during the same operative session for Blue Cross Blue Shield - Oklahoma members; applies to providers submitting claims for payment.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyMultiple Surgical Procedures-Professional Provider

Policy CodePolicy CPCP015

Change TypeNo material change

Effective DateApr 23, 2025

Next Review DateN/A

Key ActionSubmit all surgical services for the same member/date/setting by the same provider on one claim and provide supporting documentation upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%primary procedure eligible at

50%secondary/subsequent procedures eligible at

1units for bilateral modifier 50 line

add-on codesexcluded from reductions

Multiple Surgical Procedures Coverage Criteria

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Multiple Surgical Procedures Coverage Criteria

Criteria for application of multiple surgical procedure reductions and billing instructions:

ALL of the following

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

ALL of the following

ALL of the following
- Eligible at 100% of the fee schedule or billed amount, whichever is less.
- Primary procedure is the service line with the highest total allowable.
ALL of the following
- Eligible at 50% of the fee schedule or billed amount, whichever is less.

ALL of the following

Modifier 51 may be appended to indicate multiple procedures were performed during the same surgical session by the same provider but is not required.
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.

Bilateral procedure handling

Surgical procedures should be submitted with one (1) unit of service.
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 with one (1) unit of service.
Modifier 50 should be reported on one line with one unit of service when used.

ALL 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 may be considered the primary procedure if that service line has the highest allowable.

ALL of the following

The plan reserves the right to request supporting documentation; failure to adhere to coding and billing policies may impact claims processing and reimbursement.
Providers should submit claims in accordance with the Plan's billing policies and guidelines to ensure correct claim pricing methodology is applied when billing multiple surgical procedures.

Coding and Modifier Guidance

Modifiers guidanceModifier

Modifier 51	May be appended to procedure codes to reflect multiple procedures were performed during the same surgical session on the same day by the same provider, however it is not required to be added.
Modifier 50	Used for bilateral procedures; should only be reported on one line with one unit of service.

ExclusionsCPTNot Covered

Add-on codes	Excluded from multiple surgical pricing reductions.
Codes that are exempt from Modifier 51	Excluded from multiple surgical pricing reductions but can be considered the primary procedure when the service line has the highest allowable.

Primary procedure selection

Primary procedure selectionPrimary procedure = service line with the highest total allowable

Primary reimbursement ratePrimary procedure eligible at 100% of the fee schedule or billed amount, whichever is less

Secondary reimbursement rateSecondary and subsequent procedures eligible at 50% of the fee schedule or billed amount, whichever is less

Provider Actions and Claim Review

Documentation Required

Documentation Request — Submit Additional Records Upon Request

The plan reserves the right to request supporting documentation. Providers are urged to submit any additional documentation upon request; failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Denial Risk

Claim Review / Prior Authorization Risk — Claims May Be Adjusted or Denied

Claims are subject to claim review, including plan, contract, policy and code edit review, which may affect payment; providers must submit accurate, appropriately coded claims per plan billing policies to ensure correct pricing.

Submit all surgical services for the same member/date/setting by the same provider on one claim.
Use valid, industry-standard code sets and follow coding guidelines; coding software logic and code edit protocols may alter payment.

Terms and Definitions

MSPR — definition

DefinitionMultiple Surgical Procedure Reduction (MSPR) is a reduction in payment rate applied when more than one surgical procedure, assistant surgical procedure, or bi-lateral surgical procedure is performed during the same patient encounter by the same provider.

Applicability requirementsTo be considered for MSPR, services must be on the same date of service, within the same operative session, by the same provider, and at the same place of treatment.

Plan reviewMultiple surgical procedure reductions apply to all claim processing; providers should check with the Plan for exceptions.

Bilateral surgery — billing instruction

Bilateral procedure billingReport bilateral surgical procedures with one (1) unit of service and, when applicable, report Modifier 50 on one line with one unit of service.

If procedure repeated but not eligible for Modifier 50If 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 with one (1) unit of service.

Interaction with multiple surgery reductionsBilateral procedures may be subject to multiple surgical pricing reductions per the policy's pricing methodology.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyMultiple Surgical Procedures-Professional Provider

Policy CodePolicy CPCP015

Change TypeNo material change

Effective DateApr 23, 2025

Next Review DateN/A

Key ActionSubmit all surgical services for the same member/date/setting by the same provider on one claim and provide supporting documentation upon request.

SourceLink

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