CurrentFlorida BluePolicy 10-026

Multiple Surgical Procedure Reduction (Including Multiple Endoscopic Procedure Reduction)

Reimbursement policy governing payment reductions when multiple surgical or endoscopic procedures are reported by the same provider for the same patient on the same date of service; applies to all lines of business and providers billing Florida Blue (CMS-1500 or equivalent).

Policy Summary

PayerFlorida Blue

PolicyMultiple Surgical Procedure Reduction (Including Multiple Endoscopic Procedure Reduction)

Policy CodePolicy 10-026

Change TypeRevised (endoscopic RVU percentage calculation) + clarifications

Effective DateNov 15, 2008

Next Review Date

Key ActionBill surgical procedures on CMS-1500 or equivalent claim forms; reductions apply when same provider (same Federal Tax ID) reports multiple procedures on the same date of service.

SourceLink

POLICY UPDATE CHANGES

Policy was revised to include the new method of calculating the endoscopic procedure reduction based on a percentage value of the RVU and added a link to the Multiple Endoscopic Procedure Reduction list with corresponding RVU and payment percentage values.

Clarifying language added to indicate this policy applies to billing for surgical procedures on a CMS-1500 or equivalent claim form.

Modifier 50 description revised to clarify that this modifier should not be appended to designated 'add-on' codes.

100% then 50%standard reimbursement pattern

01/01/2025endoscopic payment change effective

10-026policy id

Coverage Criteria

Multiple surgical procedures, multiple endoscopic procedures and bilateral surgical procedures are subject to multiple procedure payment reduction. Reimbursement may be eligible when performed by the same physician if the procedures:

ALL of the following

add significant time or complexity to patient care
are clearly identified and defined
deserve a separate allowance for each procedure
are performed on the same date of service
Non-endoscopic codes subject to multiple procedure reduction will be reimbursed at 100% of the allowed amount for the most clinically intensive procedure (the primary procedure), then at 50% for each additional procedure allowed on the same day. Clinically intensive procedure is determined by the procedure RVU (facility or non-facility based on location of service).
Procedure codes identified as add-on or modifier 51 exempt are not subject to multiple surgical procedure reductions (see CPT Appendix D & E).
Incidental procedures will not be reimbursed separately.
Multiple endoscopic procedures: Florida Blue uses CMS endoscopic groups (MPFS MULT PROC = 3). For related endoscopic procedures within the same grouping, the primary procedure is the code with the highest facility or non-facility RVU and will be paid at 100% of the allowance; subsequent endoscopic procedures will have reduced allowances as described below.
Endoscopic payment calculation (effective 01/01/2025)
- Determine the primary (highest RVU) endoscopic procedure — paid at 100% of allowance.
- An adjusted RVU is determined by subtracting the lesser-valued endoscopy code(s) RVU from the endoscopic base code RVU.
- The adjusted RVU is divided by the lesser-valued endoscopy code(s) RVU and multiplied by 100 to determine the percent to apply to the secondary/subsequent endoscopic procedures within the same grouping.
- Multiply the fee schedule allowance of the lesser-valued endoscopy code(s) by this percentage (rounded to the nearest tenth) to determine the allowance for the secondary/subsequent endoscopic procedure(s).
- If the non-facility adjusted RVU for second/subsequent endoscopies is <= 0, use the facility RVU to determine the adjusted RVU.
Interaction with other procedures
- If one endoscopic procedure is billed with other procedures that are not endoscopies, the standard multiple surgery rules apply.
- If two unrelated endoscopies are performed on the same day, the standard multiple surgery rules apply.
- If two sets of unrelated endoscopies are performed on the same day, apply the secondary/subsequent endoscopic grouping reductions within each set, then apply multiple surgery rules; consider the total RVUs for each set of endoscopies as one service.
- If two related endoscopies and a third unrelated procedure are performed on the same day, apply the endoscopic rules to the related endoscopic procedures, then apply the multiple surgery rules treating the unrelated procedure as another service.

Coding and Modifiers

Modifiers and coding rulesModifier

modifier 50	Bilateral procedure modifier; should not be appended to designated add-on codes
modifier 51	Multiple procedures modifier; may be reported but reduction is applied per policy regardless of modifier reporting

HCPCS considerationsHCPCS

HCPCS G-range

Some G codes may be subject to multiple surgery reduction depending on code definition

Endoscopic adjusted RVU threshold

Operational ruleIf non-facility adjusted RVU for second and subsequent endoscopies is equal to or less than 0, use the facility RVU to determine the adjusted RVU for secondary and subsequent endoscopic procedures within the same grouping.

Adjusted RVU calculation (context)Adjusted RVU = base endoscopic code RVU minus lesser endoscopy code(s) RVU; percent = (adjusted RVU / lesser code RVU) * 100; allowance = lesser code fee schedule allowance * percent (rounded to nearest tenth).

When appliedThis rule applies to secondary and subsequent endoscopic procedures identified within the same CMS MPFS grouping (MULT PROC value '3').

Provider Actions and Claim Guidance

Note

General applicability and claim form guidance

This payment policy is not an authorization, certification, explanation of benefits, or guarantee of payment. It applies to billing for surgical procedures on a CMS-1500 or equivalent claim form; “same provider” means physicians and other health care professionals reporting under the same Federal Tax Identification number.

List each surgical procedure separately on the claim, placing the most significant procedure first.
Use applicable modifiers (e.g., 50 for bilateral procedures; RT/LT as appropriate). Modifier 51 may be reported, but payment reduction is applied per policy regardless of modifier reporting.
Refer to the Multiple Endoscopic Procedures Reduction link for CPT/HCPCS codes and corresponding RVU and payment percentage values when submitting endoscopic procedures.

Definitions

Multiple surgeries

DefinitionMultiple surgeries are two or more surgical procedures performed on the same day by the same physician in which duplicated elements of work and practice expense may occur; subsequent procedures are subject to reimbursement reduction.

Primary procedure determinationThe most clinically intensive procedure (highest RVU, facility or non-facility based on location of service) is designated the primary and paid at 100%.

Payment pattern (non-endoscopic)Additional allowed non-endoscopic procedures on the same day are reimbursed at 50% of the allowed amount.

Excluded itemsProcedures that are components of or incidental to a primary procedure, including intraoperative services, will not be separately reimbursed.

Bilateral surgeries

Definition