CurrentPremera BluecrossPolicy cmi_051737

Multiple Surgical Reductions (modifier 51) reimbursement

Defines identification and reimbursement adjustments when multiple surgical procedures are performed on the same patient, same date, same provider during the same surgical session for Premera Blue Cross and affiliated products.

Policy Summary

PayerPremera Bluecross

PolicyMultiple Surgical Reductions (modifier 51) reimbursement

Policy CodePolicy cmi_051737

Change TypeClarification and added denial linkage for add-on codes

Effective Date

Next Review Date

Key ActionWhen multiple applicable surgical procedures are billed for the same provider/date, reimburse the highest allowed procedure at 100% and reimburse lesser applicable procedures at 50% of the fee schedule allowance or billed charge, whichever is less.

SourceLink

POLICY UPDATE CHANGES

Removed statement 'or 50% of the per procedure billed whichever is less, per provider contract' from the surgical procedure details and added clarifying language about modifiers XE/XS/XP/XU and 59 not preventing multiple surgical reductions.

Clarified Purpose to indicate the policy pertains to professional services billed on CMS-1500 or 837P claim forms and added link reference to CMS NPFS.

Added statement that if the primary procedure code is denied, the add-on code will be denied as well.

50%allowance applied to lesser applicable procedures

100%allowance applied to highest allowed surgical procedure

Multiple annual reviewspolicy review history

17380, 17999example codes listed as exempt

Multiple Surgical Reduction Criteria

When multiple surgical procedures subject to reduction are performed by the same provider on the same date:

The surgical procedure with the highest per-procedure allowance will be reimbursed at 100% of the procedure fee schedule allowance or 100% of the procedure billed charge, whichever is less.

All other applicable lesser procedures will be reimbursed at 50% of the procedure fee schedule allowance or the per-procedure billed charge, whichever is less.50%

Modifier 51 (Multiple procedures) appended to a code does not determine which code is reduced; applicability is primarily determined by the Multiple Procedure Flag in the current CMS National Physician Fee Schedule (NPFS).

Codes identified in the NPFS with flag 9 (Concept does not apply) may be reviewed using other professional resources (e.g., AMA CPT, professional societies) to determine exceptions.

Policy Summary

PayerPremera Bluecross

PolicyMultiple Surgical Reductions (modifier 51) reimbursement

Policy CodePolicy cmi_051737

Change TypeClarification and added denial linkage for add-on codes

Effective Date

Next Review Date

SourceLink

On This Page

Relevant Modifiers, CPT Codes, and Reduction Percentage

Relevant modifiers and example CPT codesCPT

Modifier 51	Multiple procedures modifier does not determine which code is reduced
Modifiers XE, XS, XP, XU, 59	Do not prevent multiple surgical reductions from being applied
17380	Electrolysis epilation, each 30 minutes
17999	Unlisted procedure

Reduction percentage for secondary procedures

Reduction percentage for secondary proceduresAll other lesser applicable procedures will be allowed at 50% of the procedure fee schedule allowance or the per procedure billed charge, whichever is less.

Primary procedure allowanceThe surgical procedure with the highest per procedure allowance will be allowed at 100% of the procedure fee schedule allowance or 100% of the procedure billed charge, whichever is less.

ApplicabilityApplies when two or more surgical procedures subject to multiple procedure reduction are performed for the same patient on the same date of service by the same provider during the same surgical session.

Billing Rules and Add-on Code Requirements

Billing Rule

Multiple Procedure Payment Adjustment — Reimbursement Rules

When two or more surgical procedures subject to multiple procedure reduction are performed for the same patient on the same date of service by the same provider, the surgical procedure with the highest per-procedure allowance will be reimbursed at 100% of the procedure fee schedule allowance or 100% of the procedure billed, whichever is less. All other lesser applicable procedures will be reimbursed at 50% of the procedure fee schedule allowance or the per-procedure billed charge, whichever is less.

Highest allowed surgical procedure paid at 100% of fee schedule allowance or billed charge, whichever is less.
All other lesser applicable procedures allowed at 50% of fee schedule allowance or billed charge, whichever is less.

Billing Rule

Add-on Code Billing Requirement and Denial Linkage

Add-on codes are not subject to multiple surgical reduction because they describe work performed in addition to a primary procedure; however, the add-on must be billed with an appropriate primary procedure to be reimbursed. If the primary procedure code is denied reimbursement, the add-on code will be denied as well.

Add-on codes exempt from multiple surgical reductions but require an appropriate primary procedure on the claim.
Denial of the primary procedure results in denial of the associated add-on code.

Key Definitions

Multiple Procedure Flag (CMS NPFS)

DefinitionMultiple Procedure Flag — indicator in the CMS NPFS used to determine which codes are subject to multiple procedure payment adjustments (flags include 0=no adjustment, 2=standard, 3=special endoscopy, 9=concept does not apply).

Primary usePlan primarily determines codes eligible for multiple surgical reduction rules based on the NPFS Multiple Procedure Flag.

Exception handlingCodes with NPFS flag 9 may be reviewed using other resources (AMA CPT, professional societies) for exceptions.

Add-on code

DefinitionAdd-on code — a code that describes work performed in addition to the primary procedure and is not subject to multiple surgical reduction rules.

Billing requirementAdd-on surgical codes must be billed with an appropriate primary procedure in order to be reimbursed.

Denial linkageIf the primary procedure code is denied reimbursement, the add-on code will be denied as well.