CurrentUnitedHealthcarePolicy 2025R0034D

Multiple Procedure Reductions for CMS 1500 claims

Defines UnitedHealthcare Community Plan's reimbursement rules for multiple procedure reductions on services billed on CMS 1500 (and, where specified, UB04) forms; affects providers submitting claims where two or more procedures subject to multiple-procedure rules are performed by the same group physician or other qualified health care professional on the same date of service.

Policy Summary

PayerUnitedHealthcare

PolicyMultiple Procedure Reductions for CMS 1500 claims

Policy CodePolicy 2025R0034D

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate CMS 1500 claims and report correct Federal Tax Identification numbers so UnitedHealthcare can apply the appropriate multiple-procedure and endoscopic adjustment rules.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%/50%/50%Standard reduction method

100%/50%/25%Alternate reduction method

Indicators 2 & 3CMS indicators used

8/1/2016Endoscopic rule effective

Several

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Coverage Criteria — Multiple Procedure Reductions

COVERAGE CRITERIA — multiple procedure reductions apply when two or more procedures subject to reductions are performed by the Same Group Physician and/or Other Qualified Health Care Professional on the same date of service; include applicability and general rule statements.

Multiple procedure reductions apply when two or more procedures subject to reductions are performed by the Same Group Physician and/or Other Qualified Health Care Professional on the same date of service. The Multiple Procedure Reduction Codes list contains all codes that are subject to this concept. UnitedHealthcare Community Plan uses CMS multiple procedure indicators 2 and 3 in the NPFS Relative Value File to determine which procedures are eligible for multiple procedure reductions. The use of modifier 51 does not determine eligibility; modifier 78 may override reductions when appropriately reported.

All of the following apply:

- Two or more procedure codes subject to reductions are billed (i.e., two or more codes on the Multiple Procedure Reduction Codes list). If two codes are billed but only one is subject to reduction, no reduction will be taken on either procedure. (See Multiple Procedure Reduction Codes list.)

- A single code subject to the multiple procedure concept submitted with multiple units is treated similarly; reductions apply to the second and subsequent units (for example, CPT 11300 billed with 3 units). Units may also be subject to other UnitedHealthcare Community Plan policies such as Maximum Frequency Per Day Policy.

- Procedures are ranked when performed by the Same Group Physician and/or Other Qualified Health Care Professional on the same date of service to determine applicable reductions. Assistant surgeon services reported with modifiers 80, 81, 82, or AS are ranked collectively if reported by the Same Group Physician and/or Other Qualified Health Care Professional, and are ranked separately from the primary surgeon's services.

- Multiple procedure reductions do not apply to time-based anesthesia management services as identified in UnitedHealthcare Community Plan's Anesthesia Policy.

- UnitedHealthcare Community Plan applies payment indicators for HCPCS G0412-G0415 when adjudicating CPT codes 27215-27218 for purposes of this policy.

Multiple Procedure Payment Criteria — rules governing reimbursement when multiple procedures are billed on the same date of service (ranking, payment percentages, exceptions, endoscopic adjustment references).

When multiple procedures subject to the multiple procedure concept are performed on the same date of service, procedures are ranked and reimbursement is adjusted according to the applicable reduction method, with special endoscopic adjustment rules and state-specific exceptions.

Ranking and general payment rules:

- Procedures subject to the multiple procedure concept are ranked by value to determine the primary/major procedure and secondary and subsequent procedures.

- Standard Method: 100% of the Allowable Amount for the primary/major procedure; 50% of the Allowable Amount for the secondary procedure; 50% of the Allowable Amount for all subsequent procedures.

- Alternate Method: 100% of the Allowable Amount for the primary/major procedure; 50% of the Allowable Amount for the secondary procedure; 25% of the Allowable Amount for all subsequent procedures.

Coding, Modifiers, and Calculation Rules

Codes and CMS/Gap-fill handlingmixed

G0412-G0415	HCPCS payment indicators applied when adjudicating CPT 27215-27218
Gap Fill Codes	Codes without CMS RVUs use Optum The Essential RBRVS gap fill values; codes with 0.00 RVU excluded from ranking

Modifiers referenced in multiple procedure rulesModifier

26	Professional component modifier
50	Bilateral procedure modifier
51	Multiple procedures modifier (historical/used for identification)
53	Discontinued procedure modifier
62	Co-surgeon modifier
66	Two-stage or more procedures modifier
78	Unplanned return to the operating/procedure room modifier (overrides multiple procedure policy in limited cases)
80	Assistant surgeon modifier
81	Minimum assistant surgeon modifier
82	Assistant surgeon when a qualified resident is not available

1–10 of 12

1/2

Units triggering reductions

TriggerMultiple units of the same reducible code (e.g., CPT 11300 submitted with 3 units) will trigger multiple procedure reductions for the 2nd and subsequent units

ScopeApplies when a single code subject to the multiple procedure concept is submitted with multiple units on the same date of service

Interaction with other policiesUnits subject to reductions may also be subject to other UnitedHealthcare Community Plan policies such as 'Maximum Frequency Per Day'

IdentificationEligibility determined by CMS multiple procedure indicators 2 and 3 in the NPFS Relative Value File

Modifier 51Use of modifier 51 is not a factor in determining unit-level multiple procedure reductions

Provider Responsibilities and Billing Guidance

Documentation Required

Provider claim submission responsibility

You are responsible for submission of accurate claims; UnitedHealthcare Community Plan reimbursement policies are intended to ensure reimbursement aligns with the code(s) that correctly describe the services provided and UnitedHealthcare may exercise reasonable discretion when applying this policy.

Billing Rule

Modifier 51 not determinative for reductions

The presence of modifier 51 on a claim is not used to determine whether a code is subject to multiple procedure reductions; UnitedHealthcare uses CMS multiple procedure indicators (2 and 3) in the NPFS Relative Value File to identify eligible procedures.

Definitions and Policy Terms

Standard multiple procedure adjustment rules (Indicator 2)

RuleStandard payment adjustment rules apply when CMS Multiple Procedure Indicator = 2

SourceUnitedHealthcare aligns with CMS NPFS Relative Value File to identify procedures subject to Indicator 2

EffectSecondary and subsequent procedures are reduced to avoid duplicative payment components

Special rules for multiple endoscopic procedures (Indicator 3)

RuleSpecial endoscopic rules apply when CMS Multiple Procedure Indicator = 3 (related endoscopic procedures in same family)

EffectFull allowable for highest valued endoscopy in family; other endoscopies paid at endoscopic adjusted allowable calculated from Endoscopic Base Code

Policy Summary

PayerUnitedHealthcare

PolicyMultiple Procedure Reductions for CMS 1500 claims

Policy CodePolicy 2025R0034D

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate CMS 1500 claims and report correct Federal Tax Identification numbers so UnitedHealthcare can apply the appropriate multiple-procedure and endoscopic adjustment rules.

SourceLink

On This Page

- For percent of charge or discount contracts, the Allowable Amount is the billed amount less the discount; multiple procedure reductions are applicable to these contracts.

Endoscopic Adjustment Rule (exception to standard/alternate reductions for related endoscopy family procedures):

- When multiple endoscopic procedures in the same family are performed (for example diagnostic endoscopy with biopsy and polypectomy), the Endoscopic Adjustment Rule may apply instead of the standard/alternate percent reductions. Under this rule the full value of the highest valued endoscopy is paid plus an Adjusted Allowable for lesser valued endoscopy code(s) calculated as follows:

a. Adjusted RVU = Lesser valued endoscopy code RVU minus the Endoscopic Base Code RVU.

b. Percentage to Allow = Adjusted RVU divided by the lesser valued code RVU.

c. Adjusted Allowable = Lesser valued code fee schedule x Percentage to Allow.

- Example (illustrative only): For codes 45378 (base), 45380, 45385 with RVUs 6.48, 7.73, 9.17 respectively, payment would be full value of 45385 plus the Adjusted Allowable for 45380; the base diagnostic endoscopy (45378) is not reimbursed.

State and other exceptions:

- State-specific rules may require use of the Alternate Method or the Standard Method, or contain additional exceptions (examples include Florida, Idaho, Kansas, Mississippi, Missouri).

- Per state requirements, certain code pairs (for example birthing center facility fee and delivery services in Florida) may not be subject to reductions. Missouri examples: no reduction applied on a subsequent cesarean after vaginal delivery on the same date; no reduction on a second/subsequent diagnostic endoscopy when performed same date with same or different approach and different instruments; only the primary is reimbursable when more than one diagnostic endoscopy is performed same date using same approach and same instrument.

- The Multiple Procedure Reduction Codes list (CMS Physician Fee Schedule Relative Value Files) identifies codes subject to the multiple procedure concept.

- Use of modifier 51 is not a factor in determining eligibility for multiple procedure reductions; modifier 78 may override reductions when appropriately reported.

- For additional ranking examples, refer to the Questions and Answers section (e.g., surgeon and assistant surgeon claim examples).

Endoscopic Adjustment Calculation

Step 1 - Adjusted RVUAdjusted RVU = Lesser valued endoscopy RVU - Endoscopic Base Code RVU

Step 2 - Ratio to allowRatio = Adjusted RVU / Lesser valued endoscopy RVU (percentage to allow for the lesser endoscopy)

Step 3 - Adjusted allowableAdjusted allowable = Lesser valued code fee schedule x Ratio

ApplicationEndoscopic Base Code is not reimbursed; full allowable paid for highest valued endoscopy in family, adjusted allowables for lesser codes

Documentation Required

Report Federal Tax ID — Same Individual vs Same Group definitions

Providers must report the Federal Tax Identification number; ranking and application of multiple procedure rules distinguish between Same Individual (the same individual rendering services reporting the same Federal Tax ID) and Same Group (all physicians/qualified professionals reporting the same Federal Tax ID).

Implementation dateUnitedHealthcare applies CMS Endoscopic Adjustment Rules effective for dates of service 8/1/2016

RVU basis for ranking by Place of Service

Facility settingsWhen services are performed in facility POS (19,21,22,23,24,26,31,34,41,42,51,52,53,56,61), ranking uses CMS Facility Total RVUs

Non-facility settingsProcedures performed in places of service other than the listed facility POS use CMS Non-Facility RVUs for ranking

PurposeRVU basis determines primary vs secondary ranking for multiple procedure reductions

Allowable Amount — definition and determination

DefinitionAllowable Amount = the dollar amount eligible for reimbursement to the physician or other qualified health care professional on the claim

DeterminationMay be a contracted rate, reasonable charge, or billed charges as applicable; for percent-of-charge or discount contracts, the Allowable Amount is billed amount less the discount

Use in policyAllowable Amount is the basis for applying full or reduced payment under multiple procedure and endoscopic adjustment rules

Endoscopic Adjustment Rule — definition

DefinitionEndoscopic Adjustment Rule: UnitedHealthcare pays full Allowable Amount for the highest-valued endoscopy in the same family and calculates adjusted allowables for lesser endoscopies based on RVU subtraction from the Endoscopic Base Code

Calculation summaryAdjusted RVU = lesser RVU - Endoscopic Base RVU; Ratio = Adjusted RVU / lesser RVU; Adjusted allowable = lesser fee x ratio

Base code treatmentEndoscopic Base Code is not reimbursed when multiple endoscopies in the same family are reported

Same Group — definition

DefinitionSame Group: All physicians and/or other qualified health care professionals of the same group reporting the same Federal Tax Identification number

RelevanceMultiple procedure reductions apply when procedures are performed by the Same Group Physician and/or Other Qualified Health Care Professional on the same date of service

Reporting requirementProviders must report Federal Tax Identification numbers to establish group reporting for ranking and reduction purposes

Same Individual — definition

DefinitionSame Individual: The same individual rendering health care services reporting the same Federal Tax Identification number

DistinctionRanking and reductions distinguish Same Individual versus Same Group reporting for application of multiple procedure rules

Reporting requirementProviders must report the individual's billing information (including Federal Tax ID) consistent with claims to validate 'same individual' status