CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Multiple Surgery Facility reimbursement

Defines facility reimbursement rules when multiple surgical procedures are performed in the same session/place for commercial members of Anthem/Blue Cross Blue Shield products; affects facility providers submitting claims.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyMultiple Surgery Facility reimbursement

Policy CodePolicy N/A

Change TypeWisconsin reimbursement operational revision

Effective Date01/01/2022

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity guidelines and follow proper billing using industry-standard CPT/HCPCS/revenue codes.

SourceLink

POLICY UPDATE CHANGES

Updated Wisconsin exemption from 'This market is not subject to this policy' to reimburse surgeries at 100/50/50.

Added Maine exemption (market not subject to this policy).

Removed all bilateral language from policy and updated name from 'Multiple Bilateral Surgery Processing—Facility' to 'Multiple Surgery Facility'.

100/50/50Wisconsin reimbursement split (highest/2nd-5th/6th+)

01/01/2022Effective date

04/24/2024Last approval/review date

Multiple Surgery Facility — Coverage Criteria

Multiple procedure reimbursement rules

Facility reimbursement rules for multiple procedures performed same day/session/place:

Covered when ALL of the following are met:

ALL of the following

The services are performed on the same day OR during the same session and at the same place of treatment.
More than one procedure is submitted for the same surgical encounter (multiple procedures or multiple units of a single surgical procedure).
Reimbursement is limited to the primary (highest‑valued) procedure with reductions applied to additional procedures as specified by market rules.

Market-specific application

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyMultiple Surgery Facility reimbursement

Policy CodePolicy N/A

Change TypeWisconsin reimbursement operational revision

Effective Date01/01/2022

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity guidelines and follow proper billing using industry-standard CPT/HCPCS/revenue codes.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Reimbursement Details

Modifier guidanceModifier

Modifier 51

Multiple Procedures — appropriate for professional claims; should not be appended to facility claims.

Facility multiple procedure reimbursement threshold

General ruleReimbursement is allowed for only the primary (highest valued) procedure when multiple procedures are performed the same day/session/place.

Wisconsin exceptionAnthem Blue Cross and Blue Shield (Wisconsin) reimburses surgeries at 100% for the highest valued procedure; 50% for the secondary through 5th procedures; and 50% for the 6th and additional procedures.

Calculation basisReimbursement is the total of 100% of the fee schedule or contracted/negotiated rate for the highest valued procedure and the stated percentages for subsequent procedures.

ApplicabilityApplies when multiple procedures are performed the same day or same session and at the same place of treatment.

Authorization, Billing and Facility Claim Guidance

Prior Authorization

Authorization, medical necessity, and proper billing required

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis. Providers must follow proper billing and submission guidelines and use industry-standard CPT, HCPCS, and/or revenue codes; billed services must be fully supported in the medical record and/or office notes. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in recovery/recoupment of claim payment, or claim rejection/denial.

Use Current Procedure Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and/or revenue codes on all claim submissions.
Ensure billed services are fully supported in the medical record and/or office notes.
Adhere to authorization and medical necessity requirements for the procedure and diagnosis.

Billing Rule

Do not append Modifier 51 on facility claims

Do not append Modifier 51 to facility claims; reimbursement for multiple procedures in the facility setting is applied to the primary (highest valued) procedure and Modifier 51 is not appropriate on facility claims.

Modifier 51 is appropriate for professional claims but should not be appended to facility claims.
When multiple procedures are performed the facility reimbursement is limited to the primary/ highest valued procedure.

Definitions

Modifier 51 / Multiple Procedures

DefinitionMultiple Procedures: When multiple procedures (excluding specified services) are performed at the same session by the same individual; the primary procedure may be reported as listed.

Use of modifier 51Additional procedure(s) may be identified by appending modifier 51 to the additional procedure code(s) on professional claims.

Facility claims ruleModifier 51 should not be appended to facility claims.

LimitationsModifier 51 is not appropriate for designated 'add-on' codes and is intended for professional claims only.

Multiple surgeries

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

Reimbursement interactionWhen multiple surgeries occur in the same operative session, facility reimbursement follows multiple procedure reduction guidelines (primary procedure paid per policy).

ReportingAdditional procedures may be reported per professional claim conventions; facility claims should not append modifier 51.