CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Multiple procedure reductions (payment)

Defines Neighborhood Health Plan of Rhode Island's coverage and payment requirements for multiple procedure reductions when multiple procedures are performed the same day by the same physician or group; applies to Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMultiple procedure reductions (payment)

Policy CodePolicy N/A

Change TypeClarified / Revised (non-material)

Effective DateNov 2, 2020

Next Review DateN/A

Key ActionVerify member eligibility, coverage, and authorization criteria prior to services; refer to the Prior Authorization Reference and Clinical Medical Policies.

SourceLink

POLICY UPDATE CHANGES

Updated modifier 50/51 language.

Updated language for Non ASC Services.

100% / 50% / 0%ASC reimbursement tiers (highest, 2nd-5th, 6th+)

100% / 50% / 25% / 0%Non-ASC reimbursement tiers

Medicare rulesINTEGRITY lines

Medicaid, INTEGRITY, CommercialApplicable lines

50 & 51

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Multiple Procedure Reimbursement Rules

Multiple procedure reimbursement criteria

Neighborhood reimburses multiple procedures when all services are medically necessary. Reimbursement follows setting-specific reduction tiers and may vary by line of business.

Medical necessity required; Neighborhood may reference NCD, LCD, InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies to determine necessity.

Providers must verify eligibility, coverage, and authorization prior to services.

Apply Multiple Surgical Reductions (MSR) and NCCI guidelines for multiple procedures performed by the same physician or physician group on the same day.

Apply modifiers that affect payment in the first modifier field, followed by informational modifiers.

Setting-specific reimbursement rules

Ambulatory Surgery Center (ASC) services: reimburse the procedure with the highest allowed amount at 100% of the contracted rate; the 2nd–5th highest allowed amounts at 50% of the contracted rate; the 6th and any additional procedures are considered global and will not be separately reimbursed.
Non-ASC services: reimburse the procedure with the highest allowed amount at 100% of the contracted rate; the 2nd highest at 50% of the contracted rate; the 3rd–5th highest at 25% of the contracted rate; the 6th and any additional procedures are considered global and will not be separately reimbursed.

Line-of-business exception: INTEGRITY line of business: reimburse multiple procedure claims according to Medicare reduction rules for ASC and Non-ASC services.

Modifiers and Payment Thresholds

ModifiersModifier

Modifier 50	Report bilateral procedures on single claim line with a unit of 1 and modifier -50; do not report bilateral procedures as separate RT/LT lines; do not use -50 when code description indicates bilateral.
Modifier 51	Report procedures with the highest allowed procedure without the multiple procedures modifier -51; report additional same-day procedures by the same surgeon with modifier -51.

Multiple procedure payment thresholds — ASC and Non-ASC

ASC reimbursement tiersHighest allowed procedure paid at 100%; 2nd–5th highest procedures paid at 50% of contracted rate; 6th and additional procedures are global and not separately reimbursed.

Non‑ASC reimbursement tiersHighest allowed procedure paid at 100%; 2nd highest at 50% of contracted rate; 3rd–5th highest at 25% of contracted rate; 6th and additional procedures are global and not separately reimbursed.

Applicability by settingASC tiers apply to Ambulatory Surgery Centers; Non‑ASC tiers apply to services performed outside ASCs (see policy for LOB exceptions).

Verification and Authorization Requirements

Prior Authorization

Verify eligibility, coverage and prior authorization

Verify member eligibility, coverage, and any required prior authorization before providing services. Refer to the plan-specific Prior Authorization Reference page and Neighborhood Clinical Medical Policies, and contact Provider Services at 1-800-963-1001 for additional details.

Provider is responsible to verify eligibility, coverage and authorization criteria prior to rendering services.
See Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for requirements.
Contact Provider Services at 1-800-963-1001 for questions or guidance.

Key Terms

Multiple procedures — definition

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.

Payment contextSubject to multiple procedure reductions and applicable payment tiers based on setting (ASC vs Non‑ASC) and line of business.

Medical necessityAll services must be medically necessary to qualify for reimbursement; Neighborhood may reference NCDs, LCDs, InterQual, RI EOHHS, and Clinical Medical Policies to determine necessity.

Modifier 50 and 51 — bilateral and multiple procedure reporting

Modifier 50 — usageReport bilateral procedures on a single claim line with a unit of 1 and modifier -50; do not report bilateral procedures with RT and LT on two separate lines.

Modifier 50 — exceptions

Document History

2020-11-02effective_date

Policy effective date set.

2022-03-11revision

Revised language for Non-ASC services.

2023-08-01clarificationLatest

Updated modifier 50/51 language (clarification only).