March 01, 2018
Area(s) of Interest: Payor Issues and Reimbursement Practice Management
CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.
When health care providers perform multiple procedures during a single patient encounter, Medicare (and many commercial insurers) typically pay “full price” for only the highest-valued procedure. The reason is explained in Chapter 1 of the National Correct Coding Initiative (NCCI) Policy Manual:
Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. When multiple procedures are performed at the same patient encounter, there is often overlap of the pre-procedure and post-procedure work. Payment methodologies for surgical procedures account for the overlap of the pre-procedure and post-procedure work.
Under the so-called “multiple procedure rule,” Medicare pays less for the second and subsequent procedures performed during the same patient encounter. There are several ways in which reductions may be taken, as indicated for each CPT® code in column “S” of the Physician Fee Schedule Relative Value file.
If the code is assigned a “0” in column S, no payment adjustment rules for multiple procedures apply. Per the Centers for Medicare & Medicaid Services (CMS), “If procedure is reported on the same day as another procedure, base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount for the procedure.”
If the code is assigned a “1” in column S, payment adjustment rules in effect before January 1, 1995 for multiple procedures apply. In this case, the highest valued procedure will be paid at 100 percent of the fee schedule, the second most-valued procedure will be paid at 50 percent, and all subsequent procedures are paid at 25 percent.
If the code is assigned a “2” in column S, “standard “payment adjustment rules for multiple procedures apply. The highest valued procedure will be paid at 100 percent of the fee schedule, and all subsequent procedures are paid at 50 percent.
An indicator of “9” in column S means the multiple procedure reduction concept does not apply.
Special multiple procedure payment reduction rules apply in several circumstances. For example, if the code is assigned a “3” in column S and multiple endoscopic procedures within the same code family are reported, the “base” value of the endoscopy is paid only one time. You can find more information on the multiple-endoscopy rule or to learn more about special rules that apply to certain diagnostic imaging procedures, therapy services, diagnostic cardiovascular services and diagnostic ophthalmology services, visit the AAPC Knowledge Center.
Multiple procedure rule does not apply to all CPT® codes. No payor (Medicare or otherwise) should reduce payment for:
- Significant, separately identifiable evaluation and management (E/M) services provided on the same day as other procedures/services and properly appended with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service
- Any designated “add-on” CPT® code (listed with a “+” next to the descriptor)
- Any procedure designated by CPT as “Modifier 51 exempt,” which may be identified in the CPT® codebook by a “circle with a slash” next to the code.
You can find a full list of “add-on” and “modifier 51” exempt procedures in Appendices D and E of the CPT® codebook. The relative values assigned to these codes factor in the “additional” nature of the procedure/services; therefore, there is no justification to reduce reimbursement when these codes are reported in addition to other procedures.
Sequencing CPT® codes when reporting multiple procedures
CPT® includes modifier 51 Multiple procedures to indicate the same provider performed multiple procedures (other than E/M services) during the same session. Specifically, modifier 51 indicates
- The same procedure performed on different sites;
- Multiple operations during the same session; or
- One procedure performed multiple times.
When billing, recommended practice is to list the highest-valued procedure performed first, and to append modifier 51 to the second and any subsequent procedures. In practice, most billing software, and most payors, will automatically list billed codes from most-to-least valued. You can check with your payor for details, but for most payors modifier 51 is no longer necessary, regardless of how many procedures or services you report on a single claim.
Multiple procedures and correct coding edits
In some cases, NCCI may impose edits that “bundle” codes to one another. If the NCCI lists any two codes as “mutually exclusive,” or pairs them as “column 1” and “column 2” codes, the procedures are bundled and normally are not reported together. In such cases, only one procedure (the higher-valued) will be paid if both procedures are reported.
If, however, the two procedures are separate and distinct, you may be able to use a modifier to override the edit and be paid for both procedures. Separate, distinct procedures may include:
- Different session
- Different procedure or surgery
- Different site or organ system
- Separate incision/excision
- Separate lesion
- Separate injury (or area of injury in extensive injuries)
Before appending a modifier, you must confirm that unbundling is allowed for the code pair you wish to report. Each NCCI code pair edit includes a correct coding modifier indicator of “0” or “1,” as indicated by a superscript placed to the right of the column 2 code. A “0” indicator means that you may not unbundle the edit combination, under any circumstances. A “1” indicator means that you may use a modifier to override the edit, assuming the procedures are distinct.
When NCCI allows you to override a code combination edit, you will append the appropriate modifier to the “column 2” code. The most frequently-used code to overcome NCCI edits is modifier 59 Distinct procedural service, but you should append this modifier with caution. CPT® and CMS guidelines agree that modifier 59 should be the “modifier of last resort.” CPT® Appendix A explains, “Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”