Purpose:
This policy provides guidelines for appropriately billing and reimbursement for multiple surgical procedures performed in one session.

Scope:

Products included:

• NJ FamilyCare/Medicaid Plan

• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Modifier 51: Multiple procedures/surgeries performed on the same day, during the same surgical session.

Policy:

When multiple surgeries or procedures are performed by a single physician or physicians in the same group practice on the same patient at the same operative session, reduction in reimbursement for secondary procedures will apply. Horizon NJ Health shall align with the Centers for Medicare and Medicaid Services (CMS) in determining procedures that are subject to multiple procedure reductions. Procedure codes listed on the National Medicare Physician Fee Schedule Database (MPFSD) with a multiple procedure indicator of ‘2’ or ‘3’ are subject to fee reductions. Procedure codes identified as “add-on” and “modifier -51 exempt” codes are not subject to multiple surgical procedure reductions.

When two (2) or more procedure codes are subject to the multiple procedure reductions, Horizon NJ Health shall consider the procedure code with the highest allowed amount to be the primary procedure, regardless of the order in which they appear on the claim or the highest billed charges. The additional codes subject to the multiple procedure reductions are considered the secondary codes. The primary procedure shall be reimbursed at 100% of allowed charges while the secondary codes, up to two (2) additional codes, shall be reimbursed at 50% of allowed charges. Note: The use of modifier -51 is not a factor in determining which codes are considered subject to multiple procedure reductions.

Procedure:
When multiple procedures are performed in one (1) session, Horizon NJ Health shall reimburse the primary procedure, which is the procedure with the highest allowed amount, at 100% of the applicable Horizon NJ Health fee schedule. Secondary procedures that are subject to the multiple procedure reduction shall be reimbursed at 50% of the applicable Horizon NJ Health fee schedule, up to two (2) secondary codes. A total of three (3) procedures shall be reimbursed per session, the primary procedure at 100% of the applicable fee schedule and two (2) additional secondary procedures at both at 50% of the applicable fee schedule. Any additional codes eligible for the multiple procedure reduction will be denied in full after the initial three (3) are paid.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations

• The terms of any applicable provider participation agreement;

• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;

• Medical necessity; and

• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Claims Processing Manual: Chapter 12 - Physicians/Nonphysician Practitioners, Section 40.6 Claims for Multiple Surgeries

cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

NJAC § 10:54-4.16 Multiple surgical procedures; same session

CMS National Physician Fee Schedule Relative Value Files

cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html?DLSort=0&DLEntries=10&DLPage=1&DLSortDir=descending

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services