ASC Multiple Procedure Methodology
Ambulatory Surgery Center Grouper Methodology/Multiple Procedure Reduction
September 25, 2015
(see the Procedure section below for transition dates of various plans/products)
Last revised date:
June 1, 2017
Provide guidelines for the reimbursement of multiple procedures performed in an Ambulatory Surgery Center. This policy applies to ambulatory surgery centers using group methodology reimbursement only.
All products are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g.
All Insured and Administrative Services Only (ASO) accounts are included.
When applicable multiple procedures are performed in an ambulatory surgery center on the same patient during the same surgical session, multiple procedure reductions shall be applied.
Beginning September 25, 2015 and continuing as a phased in approach, Horizon BCBSNJ shall align with CMS and consider the grouper containing the procedure code with the highest allowable to be the primary procedure, regardless of the order in which they appear on the claim or the highest billed charges. All subsequent reimbursable procedures will be reduced.
Transition to the CMS grouper reimbursement methodology will occur as a phased-in approach as noted below:
|Horizon BCBSNJ plan/product||CMS grouper methodology implementation1|
|Medicare Advantage||September 25, 2015|
|Managed care network plans/products||November 9, 2015|
|Non-managed care plans/products||February 20, 2016|
|State Health Benefit Plans||April 4, 2016|
|Federal Employee Plan (FEP)||May 2, 2016|
|ITS/Par Other/MPL||September 5, 2016|
|OMNIA plans||May 15, 2017|
1Until the change in reimbursement methodology as reflected in this Policy is fully implemented systemically, ASC’s may observe some variability in reimbursement received depending on plan in which the patient is enrolled.
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.
08/15/2016: Policy approved
10/4/2016: Policy revised to include effective date for ITS/Par Other/MPL on CMS Grouper Methodology
06/01/2017: Policy revised to include effective date for OMNIA on CMS Group Methodology