CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Multiple procedure reductions (reimbursement/payment)

Defines Neighborhood Health Plan of Rhode Island's coverage and payment requirements for multiple procedure reductions for Medicaid (excluding EFP), Integrity, and Commercial lines of business; applies to providers billing surgical and radiology services.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMultiple procedure reductions (reimbursement/payment)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 2, 2020

Next Review DateN/A

Key ActionVerify member eligibility, coverage, and prior authorization requirements prior to rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%highest allowed procedure reimbursed at

50%second (and up to fifth in ASCs) reimbursed at

25%third–fifth reimbursed at (Non-ASC/Rad)

sixth+ = no separate reimbursementsixth and additional procedures

Modifiers 50/51/59/XE/XP/XS/XUmodifier guidance included

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.

Multiple Procedure Reimbursement Rules

Multiple procedure reimbursement criteria

Payment reductions apply per site of service and line of business as described below.

ALL of the following

Highest allowed procedure reimbursed at 100% of the contracted rate
Second through fifth highest allowed procedures reimbursed at 50% of the contracted rate
Sixth and any additional procedures are considered global and will not be separately reimbursed

ALL of the following

Highest allowed procedure reimbursed at 100% of the contracted rate
Second highest allowed procedure reimbursed at 50% of the contracted rate
Third, fourth, and fifth highest allowed procedures reimbursed at 25% of the contracted rate
Sixth and any additional procedures are considered global and will not be separately reimbursed

INTEGRITY line of business: ASC, Non-ASC Surgical, and Radiology services are reimbursed according to Medicare multiple-procedure reduction rules.

Scope and applicability: policy applies to Medicaid (excluding EFP), Integrity, and Commercial lines of business as specified; providers should verify member eligibility and authorization prior to services.

Modifier and Reimbursement Tier Guidance

Modifier 50Modifier

Modifier 50

Report bilateral surgical procedures on a single claim line with a unit of 1 and modifier -50; do not append -50 to CPT/HCPCS codes with 'bilateral' or 'unilateral or bilateral' in the description.

Modifier 51Modifier

Modifier 51

Report the highest allowed surgical procedure without the multiple procedures modifier -51; report additional same-day surgical procedures performed by the surgeon with modifier -51.

Modifier 59 and CMS subsets (XE/XP/XS/XU)Modifier

Modifier 59	Use to identify distinct services not normally reported together; documentation must support distinct session/site/organ/incision/lesion or area of injury.
XE	Separate Encounter - distinct because it occurred during a separate encounter.
XP	Separate Practitioner - distinct because it was performed by a different practitioner.
XS	Separate Structure - distinct because it was performed on a separate organ/structure.
XU	Unusual Non-Overlapping Service - distinct because it does not overlap usual components of the main service.

Reimbursement reduction tiers (inv-03) - CODING - key_value

ASC reimbursement tiersAmbulatory Surgery Centers: 1st procedure = 100% of contracted rate; 2nd–5th procedures = 50% of contracted rate; 6th and additional procedures = not separately reimbursed (considered global).

Non-ASC Surgical and Radiology reimbursement tiersNon-ASC Surgical and Radiology Services: 1st procedure = 100% of contracted rate; 2nd procedure = 50% of contracted rate; 3rd–5th procedures = 25% of contracted rate; 6th and additional procedures = not separately reimbursed (considered global).

Applicable lines of businessApplies to Medicaid (excluding EFP), Integrity, and Commercial lines of business per policy scope.

Payment orderingProcedures are ranked by allowed amount (highest to lowest) to determine which procedure receives full or reduced reimbursement.

Pre-service Verification and Claim Submission

Documentation Required

Pre-service verification and complete, timely claim submission

Verify member eligibility, coverage, and prior authorization requirements prior to rendering services. Submit complete claims for payment within contractually determined timely filing guidelines and include required forms for adjustments, corrections, and reconsiderations; ensure all submissions comply with National Claims Standards and applicable coding (CPT, ICD-10-CM, HCPCS).

Provider responsibility: verify eligibility, coverage, and authorization criteria before services are provided.
Timely filing: submit complete claims within contractually determined timely filing guidelines.
Corrections/adjustments: include required forms for adjustments, corrections, and reconsiderations.
Standards: comply with National Claims Standards and CPT/ICD-10-CM/HCPCS coding requirements.

Key Terms

Multiple procedures (inv-05) - DEFINITIONS - key_value

DefinitionMultiple procedures are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed.

Same-day/same-sessionIncludes procedures performed during the same operative session or on the same day by the same physician or physician group.

Payment implicationMultiple procedures may be subject to payment reductions per this policy and applicable coding edits (MSR, NCCI).

MSR/NCCI (inv-06) - DEFINITIONS - key_value

MSR/NCCI applicabilityMultiple Surgical Reductions (MSR) and National Correct Coding Initiative (NCCI) guidelines apply to multiple procedures performed by the same physician or physician group on the same day.

Modifier application