Multiple and Bilateral Surgery Reimbursement
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Defines reimbursement rules for multiple and bilateral surgical procedures for Highmark BCBS WNY members in MMC, HARP, CHPlus, and Essential Plan programs; applies to professional and facility claim billing and modifier usage.
No material clinical or coverage changes in this revision.
Multiple and Bilateral Surgery Criteria
Multiple and Bilateral Surgery Criteria
Reimbursement is allowed for multiple and bilateral procedures when all operative session, modifier, and medical necessity requirements below are met:
ALL of the following
- 100% of the fee schedule or contracted/negotiated rate for the highest-valued procedure.
- 50% of the fee schedule or contracted/negotiated rate for the 2nd through 5th procedures.
- 50% for the 6th and additional procedures only when determined to be medically necessary through clinical review.
- A single surgical procedure submitted with multiple units is subject to multiple procedure reduction guidelines.
ALL of the following
- Professional provider claims for applicable multiple surgical procedures must be billed with modifier 51 to denote additional procedures (do not append modifier 51 to designated add-on codes).
- Facility claims should not be billed with modifier 51; follow facility billing guidance and applicable contracts/state rules.
ALL of the following
- When a bilateral surgery is reported using a unilateral code, report on a single line with modifier 50 for professional and facility claims.
- Reimbursement for an appropriately reported bilateral procedure with modifier 50 is 150% of the fee schedule or contracted/negotiated rate for the procedure.
- If the code descriptor is inherently bilateral (or explicitly contains 'bilateral'), do not append LT/RT or modifier 50; reimbursement is 100% of the fee schedule or contracted/negotiated rate.
ALL of the following
- If more than one bilateral procedure or a combination of multiple and bilateral procedures are performed during the same operative session, multiple procedure reductions apply per the tiers above.
Modifiers, Codes, and Payment Reductions
| Modifier 51 | Appended to additional procedure codes to identify multiple procedures (professional claims); not appropriate for designated add-on codes. |
| Modifier 50 | Used to identify a bilateral procedure when reporting a unilateral code on a single line; not to be appended to inherently bilateral codes or designated add-on codes. |
| Modifiers LT, RT | Used to identify left-side or right-side procedures; should not be appended when code descriptor already states bilateral/unilateral or is inherently bilateral. |
Authorization and Medical Necessity
Authorization and Medical Necessity Requirements
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; use proper billing and industry-standard codes and ensure services are fully supported in the medical record or office notes. Claims may be rejected, denied, recovered, or adjusted if coding/billing guidelines or current reimbursement policies are not followed.
- Use CPT, HCPCS, and/or revenue codes that fully support services performed in the medical record.
- Follow provider, state, federal, and CMS contract mandates where they supersede this policy.
Key Terms
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