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PAP257

Multiple Procedures


Provider Administrative Policy

Section
Blue Cross of Idaho Information
Policy Date
February 2008
Status/Date
Revised/February 2014
Provider Type(s)
Ambulatory Surgery Centers   Hospitals   Physician   Podiatrists  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Policy

Multiple Procedures

Modifier 51 establishes pricing. It is important that you follow the guidelines below for correct reimbursement. If we disallow a code  as a primary procedure, we will reimburse the remaining codes as submitted following the guidelines. If you submit a corrected claim, you must resubmit the entire claim (see PAP206) with the appropriate primary surgical procedure.

Definitions
Primary procedure – The procedure with the highest billed charge. The primary procedures include, without limitation, surgical procedures and routine facility services. The primary procedure allowance is 100 percent of the Blue Cross of Idaho maximum allowance or the amount you submit for reimbursement, whichever is less.

Secondary/Tertiary procedure(s) – Procedure(s) performed subsequent to the primary procedure for which benefits are payable. The secondary and subsequent procedure(s) allowance is 50 percent of the Blue Cross of Idaho maximum allowance or the amount you submit for reimbursement, whichever is less.


Professional providers (i.e. Physician, Podiatrist, Nurse Practitioners)

When submitting a claim for multiple procedures, submit the primary procedure as the first procedure code. Use CPT modifier 51 in the first modifier position on the second and subsequent procedure code(s). You do not need a modifier if you use modifier 51 exempt or add-on codes as defined by the CPT code description. If modifier 51 is required and not received, electronic claims will error and paper claims will be returned and denied for a corrected billing.


Ambulatory Surgical Centers (ASC)

The ASC fee schedule is modeled after the Outpatient Prospective Payment System (OPPS).  ASC rules for modifier 51 application are different from CPT standard. 

When submitting a claim for multiple procedures, submit the primary procedure as the first procedure code. Use modifier 51 in the first modifier position on the second and subsequent procedures including exempt and add on codes. If modifier 51 is missing on secondary and subsequent procedures that should be stepped down in pricing, Blue Cross of Idaho may error the claim and/or return it for correction or a modifier 51 may be appended to indicate multiple procedures 


Hospitals

Exception: Hospital Services with no maximum allowance will be reimbursed based on that line of business (i.e., Traditional, PPO, Managed Care etc.). For non-fee schedule or discount from charges for services or supplies, the multiple procedure step down, as described above, may not apply. 

Blue Cross of Idaho will consider the highest billed charge as the primary procedure code taking into consideration the number of units billed. Modifier 51 will be added to secondary and subsequent surgical procedure codes to establish correct pricing.

Multiple Surgery primacy and allowances may be altered and re-priced by Provider Services upon provider appeal.


Policy History

Date Action Reason
February 2014 Revised Hospitals section language update
October 2013 Revised Added language regarding primacy and allowance upon provider appeal
May 2013 Revised Added language under surgery centers that include add on and exempt codes.
October 2011 Revised Language revision
January 2010 Moved Moved from PAP 508
March 2009 Revised ASC language added
August 2008 Revised Policy updated
May 2008 Revised Policy rewrite

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