ModifiedColorado Rocky Mountain Health PlansPolicy N/A

Multiple Procedure Reimbursement Adjustments

Defines UnitedHealthcare Community Plan's rules for ranking and reducing reimbursement when multiple procedures are performed on the same day by the same group physician or other qualified health care professional; applies to services billed on CMS-1500/CMS-1500 electronic equivalents and, when specified, UB-04 forms for UnitedHealthcare Community Plan Medicaid products.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMultiple Procedure Reimbursement Adjustments

Policy CodePolicy N/A

Change TypeAttachments updatedstate exceptions added (ID, NM)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims on CMS-1500 or electronic equivalent and bill procedures with appropriate modifiers so multiple procedure ranking and reductions are applied correctly.

SourceLink

POLICY UPDATE CHANGES

Attachments: Multiple Procedure Reduction Codes Assigned Gap-Fill RVU, Multiple Procedure Reduction Codes and Endoscopy Code Policy Table updated.

State Exceptions: Added Idaho.

State Exceptions: Added New Mexico.

100%/50%/50%Standard method

100%/50%/25%Alternate method

Indicators 2 & 3CMS indicators

Facility vs Non-Facility RVUs

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Endoscopic AdjustmentEndoscopic rule

Multiple Procedure Coverage Criteria

Multiple procedure reductions apply when two or more procedure codes subject to reductions are performed by the Same Group Physician and/or Other Qualified Health Care Professional on the same date of service, or when a single code subject to the multiple procedure concept is submitted with multiple units. The Multiple Procedure Reduction Codes list identifies codes subject to these reductions.

{

"operator":"all",

"children":[

{"text":"Two or more procedure codes on the Multiple Procedure Reduction Codes list are billed on the same date of service. If two codes are billed but only one is subject to reduction, no reduction will be taken on either procedure."},

{"text":"A single code subject to the multiple procedure concept is submitted with multiple units (e.g., CPT 11300 with 3 units). Multiple procedure reductions apply to the second and subsequent units. Units may also be subject to other policies such as maximum frequency per day."},

{"text":"Codes subject to multiple procedure reductions are determined using the CMS multiple procedure indicators (2 and 3) in the NPFS Relative Value File and applicable HCPCS payment indicators (for example, G0412–G0415 when adjudicating CPT 27215–27218). The presence of modifier 51 does not determine applicability."},

There are no modifiers that override the multiple procedure concept other than services appropriately reported with modifier 78. Co-surgeon (62) and team surgeon (66) services are ranked separately and independently when performed by the Same Individual Physician or Other Qualified Health Care Professional on the same date of service. Selected bilateral services reported with modifier 50 may also be subject to multiple procedure reductions.

]

}

Multiple procedure coverage and payment rules

When multiple procedures subject to reduction are performed on the same date of service by the Same Group Physician and/or Other Qualified Health Care Professional, procedures are ranked and reductions applied using either the Standard or Alternate method. State-specific program requirements may mandate the Alternate method or other exceptions. Endoscopic family rules and certain surgical exceptions modify the reduction calculation as described below.

{

"operator":"all",

"children":[

{"text":"Standard Reduction Method: 100% of the Allowable Amount for the primary/major procedure; 50% of the Allowable Amount for the secondary procedure; 50% of the Allowable Amount for all subsequent procedures."},

{"text":"Alternate Reduction Method: 100% of the Allowable Amount for the primary/major procedure; 50% of the Allowable Amount for the secondary procedure; 25% of the Allowable Amount for all subsequent procedures. The Alternate method is used by certain Administrative Services Only groups and by Medicaid programs that require the 100%-50%-25% method."},

Coding, Indicators, and Modifiers

CMS multiple procedure indicatorsmixed

Multiple Procedure Indicator 2	Standard payment adjustment rules for multiple procedures apply
Multiple Procedure Indicator 3	Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure).

Gap fill and 0.00 RVU codesmixed

Gap Fill Codes	When CMS does not develop RVUs, UnitedHealthcare Community Plan uses relative values published in the first quarter update of the Optum The Essential RBRVS publication for the current calendar year.
0.00 RVU Codes	Codes that cannot be assigned a gap value or remain without an RVU (for example, unlisted codes) are assigned an RVU value of 0.00 on the Multiple Procedure Reduction Codes list and will be excluded from ranking.

Modifiers applicable to multiple procedure rulesModifier

26	Professional component modifier referenced for RVU use
50	Bilateral procedure modifier referenced for processing and ranking
51	Multiple procedures modifier (not determinative of reduction eligibility)
53	Discontinued procedure modifier; use reported modifier RVU when available
62	Co-surgeon modifier; co-surgeon services are ranked separately and independently
66	Team surgeon modifier; team surgeon services are ranked separately and independently
78	Unplanned procedure during postoperative period; procedures reported with modifier 78 and a 10- or 90-day global period are not subject to multiple procedure reductions
80	Assistant surgeon modifier referenced for ranking of assistant services
81	Assistant surgeon modifier referenced for ranking of assistant services
82	Assistant surgeon (assistant at surgery) modifier referenced for ranking of assistant services

1–10 of 12

1/2

Facility vs Non-Facility ranking — inv-06: Facility vs Non-Facility ranking

Ranking basisUse CMS Facility Total RVUs to determine ranking when services are performed in a facility POS (POS 19, 21, 22, 23, 24, 26, 31, 34, 41, 42, 51, 52, 53, 56, 61).

Non-facility basisWhen services are performed outside the listed facility POS settings, rank procedures using CMS Non‑Facility RVUs.

Application scopeRanking applies to procedures performed by the Same Group Physician and/or Other Qualified Health Care Professional on the same date of service for purposes of multiple procedure reductions.

Alternate Reduction Method — inv-07: Alternate Reduction Method

Alternate reduction percentages100% of Allowable Amount for primary; 50% for secondary; 25% for all subsequent procedures.

Provider Billing and Submission Requirements

Billing Rule

Claims submission and applicability

Submit all professional services on the CMS-1500 (or electronic equivalent) with accurate, complete coding and documentation. Use CPT, HCPCS, and ICD-10 codes that most precisely describe the services rendered. Ensure claim line items include correct place of service, diagnosis pointers, units, and any applicable modifiers. Inaccurate or incomplete claims may be denied or result in incorrect payment. This policy applies to all products and to network and non-network physicians and other qualified health care professionals.

Applicable forms: CMS-1500 and electronic equivalent (and UB-04 when specified in policy).
Follow CPT, CMS and industry coding guidelines; references to CPT are definitional only.
Ensure documentation supports codes, modifiers, and medical necessity.

Billing Rule

Provider billing and modifier guidance

Report procedures with the appropriate modifiers and follow multiple-procedure ranking and reduction rules. Modifier use affects reimbursement: apply co-surgeon (62), co-surgeon-like (66), assistant surgeon (80/81), assistant-at-surgery (AS where applicable), and bilateral (50) modifiers as clinically appropriate and supported in the record. When multiple procedures are performed by the same or different providers within the same group, rank procedures by facility RVU for facility claims (use non-facility RVU for non-facility claims) to determine primary versus secondary procedure(s) and apply multiple procedure reductions (typically 100% for primary, 50% for secondary unless otherwise specified).

Definitions and Special Rules

Standard payment adjustment rules for multiple procedures — inv-10

Indicator definitionMultiple Procedure Indicator 2: standard payment adjustment rules for multiple procedures apply.

PurposeIdentifies procedures subject to the multiple procedure concept and reductions under CMS NPFS.

Policy alignmentUnitedHealthcare aligns with CMS NPFS indicators to determine which codes are subject to multiple procedure reductions and ranking by RVUs.

Special rules for multiple endoscopic procedures — inv-11

Indicator definitionMultiple Procedure Indicator 3: special rules apply for multiple endoscopic procedures within the same endoscopic base family.

Endoscopic family ruleWhen multiple endoscopies from the same family (same Endoscopic Base Code) are reported on the same day, special endoscopic adjustment rules apply per CMS NPFS.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMultiple Procedure Reimbursement Adjustments

Policy CodePolicy N/A

Change TypeAttachments updatedstate exceptions added (ID, NM)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims on CMS-1500 or electronic equivalent and bill procedures with appropriate modifiers so multiple procedure ranking and reductions are applied correctly.

SourceLink

On This Page

{"text":"For percent-of-charge or discount contracts the Allowable Amount is the billed amount less the discount; multiple procedure reductions apply to these contracts."},

{"text":"Endoscopic Adjustment Rule: For related endoscopic procedures in the same family (for example, colonoscopy with biopsy and polypectomy), the lesser valued endoscopy(s) are adjusted so payment equals the full value of the highest valued endoscopy plus the difference between the lesser endoscopy and the Endoscopic Base Code. Calculation steps: (a) Adjusted RVU = lesser endoscopy RVU − Endoscopic Base Code RVU; (b) percentage to allow = Adjusted RVU ÷ lesser endoscopy RVU; (c) Adjusted Allowable = lesser code fee schedule × percentage to allow. The Endoscopic Base Code is not separately reimbursed."},

State and program exceptions: some states (including Colorado) use the Alternate Reduction Method. Specific program rules may exempt certain procedures (for example, some birthing center or cesarean/vaginal delivery combinations) or prohibit reductions for particular subsequent procedures. Refer to state-specific guidance and the Questions & Answers examples for co-surgeon, bilateral, and endoscopy ranking scenarios.

Where usedApplied for some ASO groups and in specified state Medicaid programs (examples include Colorado, Florida, Idaho, Kansas, Missouri and others listed in state exceptions).

Contrast to standard methodDiffers from the Standard Reduction Method which is 100% primary, 50% secondary, 50% subsequent (used in many cases unless state/plan exception applies).

When a surgeon reports both primary and assistant roles during the same operative session, reductions are applied separately to surgeon-only codes and assistant-surgeon-coded services; treat those groups independently for multiple-procedure reduction purposes.
When two different physicians in the same group each report assistant surgeon services, apply multiple procedure reductions within each applicable group and reductions associated with assistant surgeon modifiers (e.g., 80, 81).
Modifiers that routinely override multiple procedure reductions are not recognized except where specifically noted (for example, modifier 78 per the policy section 'Multiple Procedures Reported with Modifier 78').
For co-surgeon reporting (modifier 62), apply multiple procedure ranking and reductions to codes reported with modifier 62 consistent with facility/non-facility RVU ranking.
When bilateral or other anatomical modifiers (e.g., 50) are reported, ensure correct application per coding guidance and that payment reflects bilateral indicators and applicable reductions.

Interaction with other reductionsEndoscopy codes billed with other reducible procedures may be subject to both endoscopic and multiple procedure reductions.

Modifier 78 — inv-12

Modifier 78 ruleModifier 78 indicates an unplanned procedure performed during the postoperative period; procedures with a 10- or 90-day global period reported with modifier 78 are not subject to multiple procedure reductions per CMS guidelines.

When to reportUse modifier 78 when another procedure is performed during the postoperative period of the initial procedure and requires use of an operating/procedure room.

ReferenceSee Questions and Answers (Q&A #6) for additional information on Modifier 78 handling.

Allowable Amount — inv-13

DefinitionAllowable Amount: the dollar amount eligible for reimbursement to the physician or other qualified health care professional on the claim (examples include contracted rate, reasonable charge, or billed charges as applicable).

Contract contextFor percent-of-charge or discount contracts, the Allowable Amount is determined as the billed amount less the discount.

Use in reductionsPrimary and secondary reimbursements are calculated as percentages of the Allowable Amount per the applicable reduction method (standard or alternate).

Endoscopic Adjustment Rule — inv-14

Endoscopic Adjustment overviewApply full Allowable Amount for the highest valued endoscopy in the family; additional endoscopies in the same family receive an Adjusted Allowable based on the NPFS Endoscopic Base Code.

Calculation approachAdjusted Allowable for lesser endoscopies is based on the NPFS-designated Endoscopic Base Code value (lesser RVU minus base RVU divided by lesser RVU, applied to fee schedule).

No reimbursement for base codeThe Endoscopic Base Code itself is not reimbursed within that family calculation when other endoscopies are performed and the adjustment rule is applied.

Endoscopic Base Code — inv-15

DefinitionEndoscopic Base Code: the most basic, least complex form of the endoscopic procedure being done.

Role in adjustmentsUsed as the NPFS-designated base when calculating adjusted allowable amounts for additional endoscopies in the same family.

Relation to familyEndoscopic Base Code identifies the family grouping for which the Endoscopic Adjustment Rule applies when multiple related endoscopies are performed on the same day.