Multiple Procedure Reduction and Endoscopic Adjustment Reimbursement Policy
Defines UnitedHealthcare Community Plan's reimbursement rules for reducing payment when multiple procedures are performed on the same day by the same group physician or other qualified health care professional; applies to services billed on CMS-1500/UB04 for UnitedHealthcare Community Plan Medicaid products.
Policy Summary
PayerUnitedHealthcare
PolicyMultiple Procedure Reduction and Endoscopic Adjustment Reimbursement Policy
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionProviders must submit accurate claims on CMS-1500 (or electronic equivalent) and use facility RVUs to rank procedures for multiple procedure reductions.
No material clinical or coverage changes in this revision.
100/50/50Standard reduction method
100/50/25Alternate reduction method
8/1/2016Endoscopic adjustment effective
ExemptAnesthesia
ListedState exceptions
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Multiple Procedure Reduction Rules
Multiple procedure reduction criteria
When multiple eligible procedure codes are performed by the Same Group Physician and/or Other Qualified Health Care Professional on the same date of service, reductions apply as follows.
Two or more procedure codes subject to reductions must be present; if two codes are billed but only one is subject to reduction, no reduction will be taken on either procedure.
Multiple units of a single reducible code are subject to reduction for the 2nd and subsequent units (e.g., CPT 11300 submitted with 3 units — reductions apply to units 2 and 3).
UnitedHealthcare uses CMS multiple procedure indicators 2 and 3 in the NPFS Relative Value File to determine which procedures are eligible for multiple procedure reductions.
Ranking of procedures uses CMS Facility Total RVUs when services are performed in a facility place of service and CMS Non‑Facility Total RVUs elsewhere to determine primary/secondary/subsequent procedures for reduction purposes.
Reduction methods (choose the method applicable by contract/state):
Standard Method: primary/major procedure paid at 100% of the Allowable Amount; secondary and all subsequent procedures paid at 50% of the Allowable Amount.
Alternate Method: primary/major procedure paid at 100% of the Allowable Amount; secondary at 50% and all subsequent procedures at 25% of the Allowable Amount (used for some ASO groups and Medicaid programs that require 100%-50%-25%).
Endoscopic Adjustment Rule applies for related endoscopies within the same endoscopic family: pay full value for the highest valued endoscopy plus adjusted allowable(s) for lesser endoscopies (the Endoscopic Base Code is not reimbursed); endoscopic adjustments may affect family RVU used for ranking against unrelated procedures.
Modifier 78 is the only modifier that overrides the multiple procedure concept when services are appropriately reported with modifier 78; no other modifiers override the policy.
When CMS assigns modifier‑specific RVUs (for modifiers such as 26, 53, TC), those modifier‑specific RVUs are used for ranking; if CMS does not assign a modifier‑specific RVU for modifier 53, the global RVU is used. Gap‑fill codes use Optum The Essential RBRVS values when available; codes with 0.00 RVU are excluded from ranking.
Assistant surgeon (80/81/82/AS), co‑surgeon/team surgeon (62/66), bilateral (50) and similar modifier‑driven services are grouped and ranked according to the policy (co‑surgeon and team surgeon services are ranked separately and independently); see Examples and Q&A for ranking illustrations.
Services considered included in another procedure (for example patient movement between suites, repositioning, re‑draping, separate incisions) are not separately reimbursed and are not eligible for additional payment under this multiple procedure policy.
Multiple procedure reduction and endoscopy adjustment criteria
Rules for applying multiple procedure reductions and endoscopic adjustments.
Co‑surgeon and team surgeon services: Multiple procedures performed by a co‑surgeon (modifier 62) or team surgeon (modifier 66) are subject to the multiple procedure concept when performed by the Same Individual Physician or Other Qualified Health Care Professional on the same date of service; co‑surgeon and team surgeon services are ranked separately and independently of other co‑surgeon/team services.
Bilateral procedures (modifier 50): Selected bilateral eligible services reported with modifier 50 may be subject to multiple procedure reductions; when split, each side is ranked separately (side 1 primary, side 2 secondary) per policy examples.
Anesthesia services exemption: Time‑based anesthesia management services are exempt from multiple procedure reductions (see Anesthesia Policy for details).
State‑specific reduction method exceptions:
Codes, Modifiers, and Gap-Fill Handling
Special HCPCS handling and gap-fill codesHCPCS
G0412-G0415
HCPCS payment indicators applied when adjudicating CPT 27215-27218
Gap-fill handling and 0.00 RVU codesHCPCS
0.00 RVU Codes
Codes assigned 0.00 RVU (eg, unlisted codes) are excluded from ranking and treated as without RVU
Optum Essential RBRVS gap-fill sourceHCPCS
Gap Fill Codes
When CMS does not assign RVUs, UnitedHealthcare Community Plan uses relative values from the Optum The Essential RBRVS first quarter update for the current calendar year
Relevant modifiersmixed
26
Professional component modifier
50
Bilateral procedure modifier
51
Multiple procedures modifier
53
Discontinued procedure modifier
62
Co-surgeon modifier
66
Team surgeon modifier
78
Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period
80
Assistant surgeon
81
Minimum assistant surgeon
82
Assistant surgeon (when a qualified resident surgeon is not available)
1–10 of 12
1/2
Modifier-specific RVU guidancemixed
Modifier 26/53/TC
When CMS assigns separate RVUs for services reported with modifiers 26, 53, or TC, the modifier-specific CMS RVUs are used for ranking in multiple procedure determinations
inv-05: Gap fill and 0.00 RVU handling
Gap‑Fill sourceWhen CMS does not assign RVUs (Gap Fill), UnitedHealthcare Community Plan uses relative values from the first‑quarter update of Optum The Essential RBRVS for the current calendar year.
0.00 RVU handlingCodes assigned a 0.00 RVU (e.g., unlisted codes or codes that cannot be gap‑filled) are excluded from ranking for multiple procedure reductions.
When gap values are availableIf Optum provides relative values for Gap Fill Codes, those assigned gap RVUs are used to determine ranking and application of reductions.
inv-06: Alternate Reduction Method values
Alternate Reduction Method (common)100% of Allowable Amount for primary/major procedure; 50% for secondary; 25% for all subsequent procedures.
Claims Submission and Billing Responsibilities
Documentation Required
Claims submission responsibility and application
You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies use Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. This reimbursement policy applies to all health care services billed on CMS-1500 forms and, when specified, to those billed on UB04 forms. Providers must follow applicable coding methodology, industry-standard reimbursement logic, regulatory requirements and benefits design when preparing claims. UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to services provided in a particular case.
Applicable claim forms: CMS-1500 (or electronic equivalent) and UB04 when specified.
Accurate coding required: use CPT/CMS and other coding guidelines to report the services actually provided.
Key Terms and Concepts
inv-09: Standard payment adjustment rules for multiple procedures apply
ApplicabilityMultiple Procedure Indicator 2: standard payment adjustment rules for multiple procedures apply to codes with indicator 2.
Alignment with CMS NPFSUnitedHealthcare uses CMS NPFS indicators to determine which procedures are subject to multiple procedure reductions.
Ranking methodProcedures are ranked using CMS Facility Total RVUs in facility settings and CMS Non‑Facility RVUs elsewhere to determine primary/secondary/subsequent order.
inv-10: Special rules for multiple endoscopic procedures
Multiple Procedure Indicator 3Indicator 3 denotes special rules for multiple endoscopic procedures when billed with another endoscopy in the same family (same Endoscopic Base Code).
Endoscopic Adjustment Rule summary
Policy Summary
PayerUnitedHealthcare
PolicyMultiple Procedure Reduction and Endoscopic Adjustment Reimbursement Policy
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionProviders must submit accurate claims on CMS-1500 (or electronic equivalent) and use facility RVUs to rank procedures for multiple procedure reductions.
States may mandate the Alternate (100%/50%/25%) or Standard (100%/50%/50%) reduction methods or other specific rules; examples include Kansas, Florida, Idaho, Mississippi, Missouri, New Mexico, Ohio, Texas, Washington, DC, Wisconsin and others as noted in the policy.
Assistant/co‑surgeon modifiers and ranking: Assistant surgeon modifiers (80, 81, 82, AS) and co‑surgeon/team (62, 66) affect grouping and ranking; services rendered in different capacities are grouped separately for ranking (see Q&A examples for application).
Endoscopic Adjustment Rule application: For multiple endoscopy codes within the same family (same Endoscopic Base Code) billed on the same day, pay full value of the highest valued endoscopy plus the Adjusted Allowable for lesser valued endoscopies calculated by: (a) Adjusted RVU = lesser RVU − Endoscopic Base Code RVU; (b) percentage to allow = Adjusted RVU ÷ lesser RVU; (c) Adjusted Allowable = lesser code fee × percentage to allow. The Endoscopic Base Code itself is not reimbursed. Family adjusted RVUs are used when comparing to unrelated procedures for ranking.
Endoscopy ranking example: When calculating family adjusted RVUs, subtract the Endoscopic Base Code RVU from lesser endoscopy RVUs and add the result to the highest family RVU to obtain Family Adjusted RVUs; compare that to unrelated procedure RVUs to determine multiple procedure ranking (see policy examples illustrating 45378/45380/45381/45562).
Operational attachments: Refer to the Multiple Procedure Reduction Codes list, Assigned Gap‑Fill RVUs attachment, and Endoscopy Code Policy Table for the code‑level RVUs, family definitions, and modifier‑specific RVU assignments used when applying these rules.
Standard Reduction Method (contrast)
Standard method reimburses primary 100%, secondary 50%, subsequent 50% (used in some states such as Mississippi per state requirement).
State variation noteStates may mandate which method to use (examples: Kansas, Florida, Idaho, Missouri, etc. use the Alternate 100%-50%-25% method; Mississippi requires 100%-50%-50%).
Billing Rule
Procedure ranking for billing
When multiple procedures are reported for services performed in a facility, providers must rank procedures using the facility (CMS) Relative Value Units (RVUs) to determine the primary versus secondary procedure for reimbursement. The procedure with the higher facility/CMS RVU is considered the primary procedure and is reimbursed at 100% of the Allowable Amount; the lower-RVU procedure(s) performed the same day are considered secondary and are subject to the multiple-procedure reduction (commonly reimbursed at 50% of the Allowable Amount when secondary).
Example: CPT 58150 (total abdominal hysterectomy) — CMS RVU 29.55 — is primary and reimbursed at 100% of Allowable Amount.
Example: CPT 57270 (repair of enterocele) — CMS RVU 23.74 — is secondary and reimbursed at 50% of Allowable Amount when performed the same day in a facility by physicians in the same group.
For endoscopies within the same family, pay full Allowable Amount for the highest valued endoscopy and pay reduced amounts for additional endoscopies based on the NPFS designated Endoscopic Base Code; the Base Code itself is not reimbursed.
Interaction with multiple procedure reductionsEndoscopies performed the same day as other procedures may be subject to both endoscopic adjustments and standard multiple procedure reductions; if endoscopies are from different families, standard multiple procedure reductions apply by RVU ranking.
inv-11: Allowable Amount
DefinitionAllowable Amount is the dollar amount eligible for reimbursement to the physician or other qualified health care professional on the claim (examples: contracted rate, reasonable charge, or billed charges as applicable).
Context of useAllowable Amount is the basis for applying multiple procedure reductions and Endoscopic Adjustment Rule calculations.
Contract variationsFor percent‑of‑charge or discount contracts, the Allowable Amount is determined as the billed amount less the discount when applicable.
inv-12: Endoscopic Adjustment Rule
Rule definitionEndoscopic Adjustment Rule: when related endoscopic procedures (within the same family) are performed on the same day, the highest valued endoscopy receives the full Allowable Amount and lower ranking endoscopies receive an adjusted allowable based on the NPFS designated Endoscopic Base Code; the Base Code is not reimbursed.
Application timingUnitedHealthcare applies CMS endoscopic adjustment rules for dates of service effective 8/1/2016 and after; related endoscopies may also be ranked against unrelated procedures for multiple procedure reductions.
Code family handlingIf multiple endoscopies are from different families, standard multiple procedure reductions are applied by RVU ranking rather than endoscopic adjustments.
inv-13: Endoscopic Base Code
DefinitionEndoscopic Base Code: the most basic, least complex form of the endoscopic procedure in the family; used as the reference value to compute adjusted allowables for additional related endoscopies.
Payment effectNo reimbursement is made for the Endoscopic Base Code when multiple endoscopies in the same family are performed; adjusted allowables for other endoscopies are based on the Base Code's value.
Reference materialA list of Endoscopy codes and Endoscopic Base Codes is provided in the policy attachments for specific family definitions and examples.
inv-14: Relative Value Units (RVU)
DefinitionRelative Value Units (RVU): the assigned unit value of a particular CPT or HCPCS code used to rank procedures for payment adjustments; values are from the CMS NPFS (Facility or Non‑Facility Total RVUs) or assigned gap‑fill sources when CMS does not provide RVUs.
SourcesPrimary source is the CMS National Physician Fee Schedule Relative Value File; Gap Fill Codes use Optum The Essential RBRVS values when available.
Use in rankingRVUs determine primary, secondary, and subsequent procedure order and are applied as Facility Total RVUs in facility settings and Non‑Facility RVUs elsewhere.