Many medical and surgical services include pre-procedure and post-procedure work, as well as generic services integral to the standard medical/surgical service. When multiple procedures are performed on the same day, by the Same Group Physician and/or Other Qualified Health Care Professional, reduction in reimbursement for secondary and subsequent procedures will occur. Payment at 100% for secondary and subsequent procedures would represent reimbursement for duplicative components of the primary procedure. The Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File identifies procedures that are subject to multiple procedure reductions. Medical and surgical services which have multiple procedure indicators 2 and 3 are subject to the multiple procedure concept and multiple procedure reductions. UnitedHealthcare aligns with CMS in determining which procedures are subject to multiple procedure reductions and the primary or secondary ranking of these procedures based on Relative Value Units.
The codes with the following CMS multiple procedure indicators are addressed within this reimbursement policy:
For endoscopy codes CMS applies special adjustment rules when multiple endoscopic procedures from the same family (same Endoscopic Base Code) are reported on the same day. CMS allows the full Allowable Amount for the highest valued endoscopy code in the family and allows any additional endoscopy codes in the same family at a reduced amount based on the value of the NPFS designated Endoscopic Base Code.
To further align with CMS, UnitedHealthcare will apply CMS multiple Endoscopic Adjustment Rules when related endoscopic procedures (within the same family) are performed on the same day. If billed on the same day as other procedures that are subject to multiple procedure reduction, endoscopy codes may be subject to the both endoscopic and multiple procedure reductions.
Find your specific codes below.
This policy contains more codes than can be displayed on one screen. Find your specific code below.