Multiple Procedure Reductions

Reimbursement Policy:

Multiple Procedure Reductions (Modifier 51)

Effective Date:

January 1, 2009

Revision Date:

November 30, 2015

Purpose:

Provide guidelines for multiple procedure reductions to eligible services, other than Evaluation and Management (E&M) services, regardless of the use of modifier 51. This policy applies to professional providers.

Scope:

All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
  • COB
  • ITS Host Medicare advantage Non-PPO
  • ITS Host Medicare Advantage PPO Non Par
  • FlexLink
  • MPL Non Par

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

  • Modifier 51:Multiple surgeries performed on the same day, during the same surgical session. Diagnostic imaging services, subject to multiple procedure reduction, provided on the same day, during the same session by the same provider.

Policy:

Horizon BCBSNJ shall align with 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.

Horizon BCBSNJ shall consider the procedure code with the highest RVU to be the primary procedure, regardless of the order in which they appear on the claim or the highest billed charges.

Examples of appropriate use of modifier 51 include, but are not limited to:

  • Appending modifier 51 when both diagnostic imaging procedures have an indicator 4 in the Medicare Physician Fee Schedule Database (MPFSDB) and both procedures have the same diagnostic imaging family indicator in the MPFSDB
  • Using modifier 51 when the same physician performs more than one surgical service during the same session, appending modifier 51 to the code with the lower physician fee schedule amount.

Examples of inappropriate use of modifier 51 include, but are not limited to:

  • Using with designated add-on-codes
  • Using with designated add-on-codes

Procedure:

In accordance with CMS guidelines, Horizon shall reimburse the primary procedure at 100% of the applicable Horizon BCBSNJ fee schedule. Secondary procedures shall be reimbursed at 50% of the applicable Horizon BCBSNJ fee schedule.

In instances where the provider is participating, based on member benefits, copayment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:

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

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

Policy 092_v1.0_02012016