Coding & Reimbursement

Medicare Rules for Multiple Procedures

By Suzanne L. Corcoran, COE

Medicare has specific rules that affect the payment when multiple surgical procedures are performed at the same session. Some of these rules are not well understood or appreciated. Let me try to provide some clarity.

Q. What is Medicare's multiple surgery rule?

A. When two surgical procedures are performed at the same session, multiple surgery rules apply. The first procedure is allowed at 100%, and the second at 50%. Additional procedures, up to five, are each allowed at 25%; more than five procedures are individually priced. These rules apply to both major procedures (those with a 90-day global period) and minor procedures (those with a 10-day or zero-day global period).

For example, when cataract surgery with an intraocular lens implant is performed on the same day as a trabeculectomy, multiple surgery rules apply. Trabeculectomy, as the higher-valued procedure, would be allowed at 100% of the Medicare Physician Fee Schedule (MPFS); the cataract surgery would be allowed at 50%.

Q. Does a payment reduction also apply to bilateral procedures?

A. Yes, since we understand that a bilateral procedure means that the service is defined as “unilateral” and performed on both sides of the body at the same operative session. An example is punctal occlusion with plugs, which is frequently performed at the same time on both lower puncta. The first would be allowed at 100%, and the second at 50% of the MPFS.

In contrast, CPT 11200 is defined as “removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions,” so this service is not inherently unilateral and your claim should not differentiate left eye or right eye.

Q. How do we report procedures that are both multiple and bilateral?

A. There are additional instructions if the multiple procedures are bilateral. The Medicare Claims Processing Manual (MCPM), Chapter 12 §40.6.C16, states, “If any of the multiple surgeries are bilateral surgeries, consider the bilateral procedure at 150% as one payment amount, rank this with the remaining procedures, and apply the appropriate multiple surgery reductions.” The effect of this approach reduces payment for the third and fourth procedure to 37.5% of the allowed amount for each procedure.

For example, the surgeon's reimbursement for a bilateral blepharoplasty performed at the same session as a bilateral brow ptosis repair would be submitted as 15823-50 (allowed at 150% of the MPFS) and 67900-50 (allowed at 75% of the MPFS). Even if each code were listed as a separate line item, the net effect would be the same, with the first procedure allowed at 100%, the second at 50%, and the third and fourth each at 37.5% of the MPFS. Note that the values of these procedures are very close. When done in a hospital outpatient department or ASC, blepharoplasty allows slightly more, so it would be ranked first.

Q. If two surgeons in the same group practice perform procedures at the same operative session, what is the effect on Medicare payment?

A. Physicians of the same specialty in a group practice function collectively as the “surgeon” and are subject to multiple surgery rules. In this context, an associate is not distinguished from the primary physician and inherits the limitations imposed by the multiple surgery policy.

The MCPM citation for global surgeries includes a reference for physicians in group practice. MCPM Chapter 12, §40.2: “When different physicians in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group.”

This concept of “surgeon” extends to multiple procedures as discussed at MCPM Chapter 12, §40.6: “Multiple surgeries 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. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day. Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure.”

For example, an anterior segment surgeon performs cataract surgery with implantation of an IOL and, at the same session, her partner, a retina surgeon, performs a pars plana vitrectomy. Even though these are different surgeons, when they operate together at the same session, Medicare allows one procedure at 100% and the other at 50% (in this case, the vitrectomy has a higher value, so the cataract surgery payment would be reduced).

This discussion emphasizes Medicare's global surgery policy. Other third-party payers are not bound to follow Medicare's policy. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.