Physicians & Other Health Care Professionals

The information below provides a high-level overview of HCS reimbursement guidelines. HCS uses general industry standards to calculate medical bill reimbursement.

Reimbursement methodologies may change from time to time in accordance with HCS policy or applicable laws or regulations.

The HCS allowed amount is calculated at:

• the lesser of charges;
• the usual, customary and reasonable (UCR) amount;
• the HCS contracted rate or any applicable state fee schedule amount, including but not limited to the New Jersey personal injury protection (PIP) Fee Schedule amount.

• The HCS multiple surgical procedure reduction policy applies when billing for multiple surgical procedures rendered by the same physician in the same operative session.
• Surgical procedures are ranked in descending order based on the Personal Injury Protection (PIP) fee schedule amount, or the usual, customary, and reasonable (UCR) amount, whichever is applicable.
• The surgical procedure with the highest value is reimbursed at 100 percent of the HCS allowed amount. Additional surgical procedures are reimbursed at 50 percent of the HCS allowed amount. Additional procedures should be billed using modifier 51.
• Exceptions to the multiple surgical procedure reduction policy include “add-on codes,” which relate to procedures that are distinct from other surgical procedures being performed. These procedures are reimbursed at 100 percent of the HCS allowed amount.

Eligible bilateral surgical procedures are reimbursed at 150 percent of the HCS allowed amount. Bilateral procedures should be billed using modifier 50.

• Co-surgeons are defined as two surgeons, usually in different specialties, working together during the same operative session as primary surgeons performing distinct parts of a procedure. Reimbursement for each physician is at 62.5 percent of the HCS allowed amount for each procedure. Procedures involving co-surgeons should be billed using modifier 62.
• An assistant surgeon is defined as a physician who assists the primary surgeon in performing a surgical procedure.
• Reimbursement for services rendered by an assistant surgeon is at 20 percent of the HCS allowed amount for each procedure. Procedures involving assistant surgeons should be billed using modifier 80, 81, or 82.
• A non-physician assistant surgeon is defined as a highly skilled individual with specialty training in providing assistance during surgical procedures. Reimbursement for services rendered by a non-physician assistant surgeon is at 17 percent of the HCS allowed amount for each procedure. Procedures involving non-physician assistant surgeons should be billed using modifier AS.

• When billing for anesthesia services, health care professionals are required to use the applicable CPT modifiers to identify whether services were performed by an anesthesiologist or other qualified individual under the supervision of a physician.
• Each anesthesia code is assigned a base unit value by the American Society of Anesthesiologists (ASA) and used for the purpose of establishing allowances. The amount of time for anesthesia services must be reported in minutes. Each time unit is equal to 15 minutes; a period less than a unit will be rounded up to the next unit if the remaining minutes is equal to or greater than 5.
• Anesthesia services performed personally by the anesthesiologist are reimbursed at 100 percent of the HCS allowed amount. Such services should be billed using modifier AA.
• When the anesthesiologist is not personally performing the anesthesia service but is directing one or more certified registered nurse anesthetists (CRNAs), the reimbursement is calculated at 50 percent of the HCS allowed amount. Such services should be billed using modifier QY (one CRNA), QK (2-4 CRNAs) or AD (5 or more).

Certified registered nurse anesthetists (CRNA) services are only eligible for reimbursement when performed under the supervision or direction of a physician anesthesiologist. Reimbursement for services rendered by CRNAs is calculated at 50 percent of the HCS allowed amount. Such services should be billed using modifier QX when services are performed with medical direction by an anesthesiologist or modifier QZ when services are performed without medical direction by an anesthesiologist.