multiple procedures payment reduction (mppr) for medical and … · 2 days ago · multiple...

Multiple Procedures Payment Reduction (MPPR) for Medical and Surgical Services Policy of 17 UnitedHealthcare Oxford Reimbursement Policy Effective 07/01/2020

©1996-2020, Oxford Health Plans, LLC

MULTIPLE PROCEDURES PAYMENT REDUCTION (MPPR)

FOR MEDICAL AND SURGICAL SERVICES POLICY Policy Number: SURGERY 022.39 T0 Effective Date: July 1, 2020 Table of Contents Page INSTRUCTIONS FOR USE .......................................... 1 APPLICABLE LINES OF BUSINESS/PRODUCTS .............. 1 APPLICATION .......................................................... 1 OVERVIEW .............................................................. 1 REIMBURSEMENT GUIDELINES .................................. 2 DEFINITIONS .......................................................... 5 QUESTIONS AND ANSWERS ...................................... 5 APPLICABLE CODES ................................................. 8 REFERENCES .......................................................... 16 POLICY HISTORY/REVISION INFORMATION ................ 17 INSTRUCTIONS FOR USE The services described in Oxford policies are subject to the terms, conditions and limitations of the member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required

by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded members and certain insured products. Refer to the member specific benefit plan document or Certificate of Coverage to determine whether coverage is provided or if there are

any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member specific benefit plan document or Certificate of Coverage, the member specific benefit plan document or

Certificate of Coverage will govern. UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.

APPLICABLE LINES OF BUSINESS/PRODUCTS This policy applies to Oxford Commercial plan membership. APPLICATION

This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500)

or its electronic equivalent or its successor form. This policy applies to all products, all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. OVERVIEW

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 Healthcare 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.

Related Policies

• Refer to the Reimbursement Guidelines section of the policy

UnitedHealthcare® Oxford

Reimbursement Policy



The Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File identifies procedures that are subject to the multiple procedure reductions. Medical and surgical services which have multiple procedure indicators 2 and 3 are subject to multiple procedure concept and multiple procedure reductions. Oxford aligns with CMS in determining which procedures are subject to multiple procedure reductions and the primary

or secondary ranking of these procedures based on the Relative Value Units. The codes with the following CMS multiple procedure indicators are addressed within this reimbursement policy: • Multiple Procedure Indicator 2 - Standard payment adjustment rules for multiple procedures apply • Multiple Procedure Indicator 3 - Special rules for multiple endoscopic procedures apply if procedure is billed with

another endoscopy in the same family (i.e., another endoscopy that has the same base procedure).

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, Oxford 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. REIMBURSEMENT GUIDELINES Multiple Procedure Concept

Multiple procedure reductions apply when: • There are two or more procedure codes subject to reductions (i.e., two or more codes on the Multiple Procedure

Reduction Codes List). If two codes are billed but only one is subject to reduction, no reduction will be taken on either procedure;

• A single code subject to the multiple procedure concept is submitted with multiple units. For example, CPT code 11300 is submitted with 3 units. Multiple procedure reductions would apply to the second and third unit. The units may also be subject to Oxford’s other policies, such as Maximum Frequency Per Day Policy.

Oxford uses the CMS multiple procedure indicators 2 and 3 in the NPFS Relative Value File to determine which

procedures are eligible for multiple procedure reductions. The use of modifier 51 appended to a code is not a factor in determining which codes are considered subject to multiple procedure reductions.

In addition, Oxford applies the payment indicators for HCPCS codes G0412-G0415 when adjudicating CPT codes 27215-27218 for the purposes of this policy.

The Multiple Procedure Reduction Codes list contains all codes that are subject to the multiple procedure concept as described above. • Multiple Procedure Reduction Codes List • CMS Physician Fee Schedule Relative Value Files Endoscopic Procedures

When related endoscopic procedures (within the same family) are performed on the same day, the lower ranking endoscopy codes will receive an adjustment under the Endoscopic Adjustment Rule to reduce the Allowed Amount based on the amount of the Endoscopic Base Code. No reimbursement will be made for the Endoscopic Base Code.

Multiple endoscopies in the same family performed on the same day as other procedures subject to multiple procedure reduction will be ranked accordingly and may be subject to endoscopic and multiple procedure reduction. Refer to the

list of Endoscopy and Endoscopic Base Codes. Refer to the Questions and Answers section, Q&A #7 and Q&A #8, for examples of how the Endoscopic Adjustment Rule will be applied.

If two or more endoscopic procedures are performed on the same day from different families, the multiple procedure reduction will be applied to the endoscopic codes with the lower RVU values. Additional Services

Additional reimbursement will not be allowed for the following services which are considered included in the procedure being performed: • Moving a patient from one surgical suite to another surgical suite to perform an additional procedure • Repositioning a patient

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/attachments/oxford/multiple-procedures-ohp-reduction-code-list.pdf



http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html



• Redraping a patient • Separate incisions or operative sites Multiple Procedure Reductions

Multiple procedures subject to the multiple procedure concept (as described above) performed by the Same Group Physician and/or Other Health Care Professional on the same date of service are ranked to determine applicable

reductions. There are no modifiers that override the multiple procedure concept other than those services which are appropriately reported with modifier 78. Multiple Procedure Ranking

Oxford uses the CMS Facility Total RVUs to determine the ranking of primary, secondary and subsequent procedures when those services are performed in a facility setting (Place of Service [POS] 19, 21, 22, 23, 24, 26, 31, 34, 41, 42, 51, 52, 53, 56 and 61). Procedures performed in a place of service other than the facility POS setting will be ranked by the CMS Non-Facility RVUs.

Examples:

Note: RVU values in these examples may not accurately reflect the current NPFS and are intended for illustrative purposes only.

POS 11 (Office)

Code Description Units Non-Facility Total

RVUs

Facility

Total RVUs Multiple Procedure Ranking

11012 Debride skin/muscle/bone, fx 1 18.59 11.50 1 – Primary

14301 Adjacent skin tissue rearrangement

1 18.56 16.16 2 – Secondary

POS 22 (Outpatient Hospital)

Code Description Units Non-Facility Total

RVUs

Facility

Total RVUs Multiple Procedure Ranking

11012 Debride skin/muscle/bone, fx 1 18.59 11.50 2 – Secondary

14301 Adjacent skin tissue rearrangement

1 18.56 16.16 1- Primary

Exception for New York Commercial Lines of Business: Oxford will determine the Primary Procedure based on the code with the highest maximum Allowable Amount for contracted providers. For services supplied by providers who are not contracted with Oxford, Oxford will compare the UCR amounts for each code and use the code with the highest UCR as the primary procedure. Multiple Procedure Reduction Codes with Assigned RVUs Reported with Modifiers 26, 53, TC

For certain codes that are subject to multiple procedure reductions CMS has assigned separate RVU values when reported with modifiers 26, 53, and TC. When these modified services are billed with other services subject to the multiple procedure concept, the CMS RVUs associated with the reported modifier 26, 53, or TC are used in

determining which services should be reduced according to the multiple procedure concept. Example: Note: RVU values in this example may not accurately reflect the current NPFS and are intended for illustrative purposes only.

522xx was reported with the professional component for 517xx (Modifier 26) in POS 11(office). The global procedure

(517xx) is not applicable in this example.

Code Modifier Non-Facility RVU Facility RVUs RVU Used for

Ranking Multiple Procedure Ranking

522xx 8.25 5.25 8.25 1 - Primary

517xx 9.00 6.00 Not applicable Not applicable

517xx 26 3.15 1.45 3.15 2 - Secondary

Note: Multiple procedure reduction codes may be reported with modifier 53 that have not been assigned a separate RVU for modifier 53 by CMS. In these situations the global RVU is used for multiple procedure ranking.



Refer to the Multiple Procedure Reduction Codes list for all codes subject to multiple procedure reductions that have a separate RVU value associated with the 26, 53, or TC modifier.

Multiple Procedure Reduction Codes with No Assigned CMS RVU

Services that CMS indicates may be carrier-priced, or those for which CMS does not develop RVUs are considered Gap

Fill Codes and are addressed as follows: • Gap Fill Codes: When data is available for Gap Fill Codes, Oxford uses the relative values published in the first

quarter update of the Optum, The Essential RBRVS publication for the current calendar year. Multiple Procedure Reduction Codes Assigned Gap Fill RVUs

• 0.00 RVU Codes: Some codes cannot be assigned a gap value or remain without an RVU due to the nature of the service (example: unlisted codes). These codes are assigned an RVU value of 0.00 on the Multiple Procedure Reduction Codes list and will be ranked as secondary or subsequent procedures when reported with other

procedures that are subject to the multiple procedure concept described above. Examples: Note: RVU values in this example may not accurately reflect the current NPFS and are intended for illustrative purposes only.

Code Billed Charge RVU Multiple Procedure Ranking

15946 $2000.00 46.96 1-Primary

15956 $2000.00 33.09 2-Secondary

15999 $2500.00 0.00 3-Tertiary

In the instance where multiple procedure codes assigned an RVU of 0.00 are reported, the ranking of these procedures will be based on billed charges, meaning, the procedure code with the highest billed charge would be considered the primary procedure.

Code Billed Charge RVU Multiple Procedure Ranking

15999 $2500.00 0.00 1-Primary

15877 $1500.00 0.00 2-Secondary

Multiple Procedures Reported with Modifier 78

Per CPT, it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it should be reported by adding modifier 78 to the related procedure. In accordance with CMS guidelines, procedures reported with a modifier 78 that have a 10 or 90 day global period are not subject to the multiple procedure concept.

For additional information, refer to the Questions and Answers section, Q&A #6. Multiple Procedures for Assistant Surgeon Services Reported with Modifiers 80, 81, 82, AS

When services are reported by more than one assistant surgeon using modifiers 80, 81, 82 or AS those services will be ranked collectively if reported by the Same Group Physician and/or Other Health Care Professional. Assistant surgeon services will be ranked separately from the services reported by the primary surgeon. Refer to the Questions and Answers section, Q&A #3, for an example of multiple procedure ranking on an assistant

surgeon claim. Multiple Procedures for Co-Surgeon/Team Surgeon Services Reported with Modifiers 62, 66

Multiple procedures performed by a co-surgeon (modifier 62) or team surgeon (modifier 66) are subject to the multiple procedure concept as defined above when performed by the Same Individual Physician or Other Health Care Professional on the same date of service. Co-surgeon and team surgeon services are ranked separately and independently of any other co-surgeon or team surgeon services. Refer to the Questions and Answers section, Q&A #5 for an example of multiple procedure ranking on a co-surgeon

claim.



Multiple Procedures for Bilateral Surgeries Reported with Modifier 50, LT, RT

Selected bilateral eligible services may also be subject to multiple procedure reductions when billed alone or with other multiple procedure reduction codes.

Refer to the Questions and Answers section, Q&A #4, for an example of multiple procedure ranking on a bilateral procedure.

DEFINITIONS Allowable Amount: Defined as the dollar amount eligible for reimbursement to the physician or health care professional on the claim. Contracted rate, reasonable charge, or billed charges are examples of Allowable Amounts. For percent of charge or discount contracts, the Allowable Amount is determined as the billed amount, less the discount.

Endoscopic Adjustment Rule: Allows the full Allowable Amount for the highest valued endoscopy code and allows any additional endoscopy codes (within the same family) at a reduced amount based on the value of the NPFS designated Endoscopic Base Code. Endoscopic Base Code: The most basic, least complex form of the endoscopic procedure being done.

Gap Fill Codes: Codes for which CMS does not develop RVUs. Relative values are therefore assigned based on the first quarter update of Optum The Essential RBRVS publication for the current calendar year. Relative Value Unit (RVU): The assigned unit value of a particular CPT or HCPCS code. Same Individual Physician or Other Qualified Health Care Professional: The same individual rendering health

care services reporting the same Federal Tax Identification number. Same Group Physician and/or Other Qualified Health Care Professional: All physicians and/or other qualified health care professionals of the same group reporting the same Federal Tax Identification number. QUESTIONS AND ANSWERS

1

Q:

Which procedure would be primary when CPT code 58150 (total abdominal hysterectomy) and CPT code

57270 (repair of enterocele) are performed in a facility and reported by two different specialty physicians

within the same group practice?

A:

Multiple procedure ranking is based on the facility RVUs. CPT code 58150 is the primary procedure with the higher CMS RVU value of 29.55 and CPT code 57270 is the secondary procedure with the lower CMS RVU of 23.74. CPT code 58150 would be reimbursed at 100% of the Allowable Amount, and CPT code 57270 would be reimbursed at 50% of the Allowable Amount.

Note: RVU values in this example may not accurately reflect the current NPFS and are intended for illustrative purposes only.

Two Different Specialty

Physicians/ Same Group Code

Non-Facility RVU Facility RVU

RVU used for ranking

Multiple Procedure Ranking

Dr. A 57270 29.22 23.74 23.74 – facility 2 – Secondary

Dr. B 58150 34.01 29.55 29.55 – facility 1 – Primary

2

Q: Are multiple procedure reductions applied when the same individual surgeon reports multiple procedure

reduction codes while acting as both surgeon and assistant surgeon during the same operative session?

A:

Yes, however the surgeon is acting in two different capacities, as surgeon and assistant surgeon. This means all multiple procedure reduction codes reported by the surgeon (with no assistant surgeon modifier) are ranked as one group and all multiple procedure reduction codes reported with an assistant surgeon modifier are ranked as a second group, independent of each other.

3

Q: Are multiple procedure reductions applied when two different physicians within the same group practice each report assistant surgeon services, Dr. A reports 19307-80 and the Dr. B reports 19367-81?

A:

Yes. A multiple procedure reduction would be applied to CPT code 19307-80 (the secondary code). In addition, both 19307-80 and 19367-81 would be subject to reduction based on the assistant surgeon modifiers (e.g. 80, 81).




Two Different Physicians/ Same Group Code

Non-Facility RVU

Facility RVU

RVU Used for Ranking

Multiple Procedure Ranking Applicable Reductions

Dr. A 19307-80 34.16 34.16 34.16 2 –

Secondary

50% of the Allowable

Amount for multiple procedure subject to modifier 80 assistant surgeon reduction.

Dr. B 19367-81 53.54 53.54 53.54 1 - Primary 100% of the Allowable Amount for multiple procedure subject to modifier 81 assistant surgeon reduction.

4

Q: How is multiple procedure ranking applied to a bilateral eligible procedure reported with a modifier 50?

A:

When the bilateral code is split for processing, each side is considered separately for ranking when a multiple procedure reduction applies. Side 1 is considered primary and side 2 will be ranked secondary.


Line Bilateral Code Charge


1 19361-50 $2000.00 1 – Primary 100% of the Allowable Amount

2 19361 $2000.00 2 – Secondary 50% of the Allowable Amount

5

Q: How is multiple procedure ranking applied when two different physicians in the same group practice each report multiple co-surgeon services eligible for multiple procedure reductions on the same day?

A:

Each co-surgeon’s services are ranked separately and independently of the other regardless of whether they are in the same group practice. In addition, each co-surgeon’s services are subject to reduction based on the co-surgeon modifier (62) reported.


Services reported by Dr. A - CPT 19361-62, RVU = 29, CPT 19340-62, RVU = 20

Services reported by Dr. B - CPT 19361-62, RVU = 29, CPT 19340-62, RVU = 20

Dr. A Code Charge


1 19361-62 $4000.00 1 – Primary 100% of the Allowable Amount for multiple procedure subject to modifier 62 co-surgeon

reduction

2 19340-62 $1600.00 2 – Secondary 50% of the Allowable Amount for multiple procedure subject to modifier 62 co-surgeon reduction

Dr. B Code Charge


1 19361-62 $4000.00 1 – Primary 100% of the Allowable Amount for multiple procedure subject to modifier 62 co-surgeon reduction

2 19340-62 $1600.00 2 – Secondary 50% of the Allowable Amount for multiple procedure subject to modifier 62 co-surgeon reduction

6

Q: Are there any modifiers that will override the multiple procedure policy?

A: No, other than those services which are appropriately reported with modifier 78 as described in the section of this policy titled ‘Multiple Procedures Reported with Modifier 78’.



7

Q: How will the Endoscopic Adjustment Rule be applied to multiple endoscopy codes within the same family (same Endoscopic Base Code) billed on the same day by the Same Group Physician and/or Other Health Care Professional?

A:

Below is an example of how the Endoscopic Adjustment Rule will be applied:

In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 percent for the highest valued procedure (45385)

and 50 percent for the next (45380), the Endoscopic Adjustment Rule will pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378) or Adjusted Allowable for (45380).

The calculation of the Adjusted Allowable for the lesser valued endoscopy code(s) in the same family is as follows: a. Determine the Adjusted RVU: Lesser valued endoscopy code(s) RVU minus the Endoscopic Base Code

RVU b. Determine the Percentage to Allow: Adjusted RVU (Step 1a) divided by the lesser valued RVU = ratio

(percentage to allow for the lesser valued endoscopy code).

c. Determine the Adjusted Allowable for the lesser code(s): Lesser valued code fee schedule x ratio

(Step 1b) = endoscopic adjusted allowable for the lesser valued code. Based on the following RVUs for these codes if the procedures were performed in a facility: 45378 (6.48), 45380 (7.73) and 45385 (9.17), Oxford would reimburse the full value of 45385 ($374.56), plus the Adjusted Allowable for 45380 ($45.76). The Endoscopic Base Code (45378) is not reimbursed.

Note: RVU values and dollar amounts in this example may not accurately reflect the current NPFS and are intended for illustrative purposes only.

Code Description Facility

RVU Adjusted

RVU Percentage to

Allow Adjusted Allowable

45378

Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing,

when performed (separate procedure)

6.48

Endoscopic

Base Code =

not allowed

N/A N/A

45380 Colonoscopy, flexible; with biopsy, single or multiple

7.73 7.73 – 6.48

= 1.25 1.25/7.73 = 16%

285.98 x 16% = $45.76

45385

Colonoscopy, flexible; with removal of tumor(s),

polyp(s), or other lesion(s) by snare technique

9.17 Highest

RVU – no adjustment

100% $374.56 – no

adjustment

.

8

Q: How will the Endoscopic Adjustment Rule be applied to multiple endoscopy codes within the same family and another procedure that is not related?

A:

Below is an example of how the Endoscopic Adjustment Rule and multiple procedure reduction will be applied when the physician bills for codes 45380 and 45381 (same endoscopic family) and 45562 (unrelated procedure).

a. First determine the Total Adjusted RVU for each endoscopic family. Each “family” of endoscopic codes is considered as a single procedure (RVUs combined) for ranking.

b. Rank the Family Adjusted RVUs against other reducible procedures RVUs from highest to lowest.

c. Apply the Multiple Procedure Reduction (Example: Standard reduction of 100-50-50).

Based on the following RVUs for these codes if the procedures were performed in a facility: 45378 (6.48),

45380 (7.73), 45381 (7.34) and 45562 (33.19), first calculate the Total Adjusted RVUs based on the Endoscopic Adjustment Rule by subtracting the difference between the Endoscopic Base Code and the lower valued endoscopy code (.86) and then adding that calculation to the higher valued endoscopy code (7.73), which equals (8.56). Compare the Family Adjusted RVUs (8.56) to the RVUs of the unrelated procedure (33.19) to determine Multiple Procedure Ranking.

Note: RVU values and dollar amounts in this example may not accurately reflect the current NPFS and are



intended for illustrative purposes only.

Code Description Facility

RVU

Total Adjusted

RVU

Family Adjusted

RVU

Multiple Procedure Ranking

Multiple Procedure Reduction

45378

Colonoscopy, flexible; diagnostic, including collection of

specimen(s) by brushing or washing, when performed (separate procedure)

6.48 Endoscopic

Base Code = not allowed

N/A N/A N/A

45380

Colonoscopy, flexible; with biopsy, single or

multiple 7.73

Highest RVU – no adjustment

7.73 + .86 = 8.56

2

50%

45381

Colonoscopy, flexible; with directed submucosal injection(s), any substance

7.34 7.34 – 6.48 =

.86

45562 Exploration, repair, and presacral drainage for rectal injury

33.19 Unrelated Procedure

N/A 1 100%

.

APPLICABLE CODES

Multiple Procedure Reduction Codes

A list of codes that are subject to multiple procedure reductions: Multiple Procedure Reduction Codes.

CPT Code RVU

Multiple Procedure Reduction Codes Assigned Gap Fill RVUs

Codes on the Multiple Procedure Reduction Codes List that have been assigned gap fill RVUs

0308T 41.73

15824 32.72

15825 36.81

15826 26.58

15828 69.53

15829 77.71

17380 2.17

21742 34.93

21743 45.96

24940 30.75

41820 7.00

41821 1.57

41850 3.50

41870 8.74

54440 16.25

58974 4.15

92992 30.98

92993 24.50

93530 22.88

93531 49.52

93532 59.64

93533 50.20

93619 19.95




CPT Code RVU

93620 24.35

93624 9.29

93640 13.00

93641 17.15

CPT® is a registered trademark of the American Medical Association

Endoscopy CPT Code Endoscopy EndoBase CPT Code Family Grouper

Endoscopy Codes

Endoscopy and Endoscopic Base Codes that are subject to the Endoscopic Adjustment Rule

29806 29805 1

29807 29805 1

29819 29805 1

29820 29805 1

29821 29805 1

29822 29805 1

29823 29805 1

29824 29805 1

29825 29805 1

29827 29805 1

29828 29805 1

29834 29830 2

29835 29830 2

29836 29830 2

29837 29830 2

29838 29830 2

29843 29840 3

29844 29840 3

29845 29840 3

29846 29840 3

29847 29840 3

29861 29860 4

29862 29860 4

29863 29860 4

29871 29870 5

29873 29870 5

29874 29870 5

29875 29870 5

29876 29870 5

29877 29870 5

29879 29870 5

29880 29870 5

29881 29870 5

29882 29870 5

29883 29870 5

29884 29870 5

29885 29870 5

29886 29870 5

29887 29870 5




Endoscopy Codes


29914 29860 4

29915 29860 4

29916 29860 4

31233 31231 34

31235 31231 34

31237 31231 34

31238 31231 34

31239 31231 34

31240 31231 34

31241 31231 34

31253 31231 34

31254 31231 34

31255 31231 34

31256 31231 34

31257 31231 34

31259 31231 34

31267 31231 34

31276 31231 34

31287 31231 34

31288 31231 34

31290 31231 34

31291 31231 34

31292 31231 34

31293 31231 34

31294 31231 34

31295 31231 34

31296 31231 34

31297 31231 34

31298 31231 34

31510 31505 6

31511 31505 6

31512 31505 6

31513 31505 6

31527 31525 7

31528 31525 7

31529 31525 7

31530 31525 7

31531 31526 8

31535 31525 7

31536 31526 8

31540 31525 7

31541 31526 8

31545 31526 8

31546 31526 8

31560 31525 7




Endoscopy Codes


31561 31526 8

31570 31525 7

31571 31526 8

31572 31575 9

31573 31575 9

31574 31575 9

31576 31575 9

31577 31575 9

31578 31575 9

31579 31575 9

31623 31622 10

31624 31622 10

31625 31622 10

31628 31622 10

31629 31622 10

31630 31622 10

31631 31622 10

31634 31622 10

31635 31622 10

31636 31622 10

31638 31622 10

31640 31622 10

31641 31622 10

31645 31622 10

31647 31622 10

31648 31622 10

31660 31622 10

31661 31622 10

38570 49320 24

38571 49320 24

38572 49320 24

38573 49320 24

43192 43191 11

43193 43191 11

43194 43191 11

43195 43191 11

43196 43191 11

43198 43197 12

43201 43200 13

43202 43200 13

43204 43200 13

43205 43200 13

43206 43200 13

43210 43235 14

43211 43200 13




Endoscopy Codes


43212 43200 13

43213 43200 13

43214 43200 13

43215 43200 13

43216 43200 13

43217 43200 13

43220 43200 13

43226 43200 13

43227 43200 13

43229 43200 13

43231 43200 13

43232 43200 13

43233 43235 14

43236 43235 14

43237 43235 14

43238 43235 14

43239 43235 14

43240 43235 14

43241 43235 14

43242 43235 14

43243 43235 14

43244 43235 14

43245 43235 14

43246 43235 14

43247 43235 14

43248 43235 14

43249 43235 14

43250 43235 14

43251 43235 14

43252 43235 14

43253 43235 14

43254 43235 14

43255 43235 14

43257 43235 14

43259 43235 14

43261 43260 15

43262 43260 15

43263 43260 15

43264 43260 15

43265 43260 15

43266 43235 14

43270 43235 14

43274 43260 15

43275 43260 15

43276 43260 15




Endoscopy Codes


43277 43260 15

43278 43260 15

44361 44360 16

44363 44360 16

44364 44360 16

44365 44360 16

44366 44360 16

44369 44360 16

44370 44360 16

44372 44360 16

44373 44360 16

44377 44376 17

44378 44376 17

44379 44376 17

44381 44380 36

44382 44380 36

44384 44380 36

44389 44388 18

44390 44388 18

44391 44388 18

44392 44388 18

44394 44388 18

44401 44388 18

44402 44388 18

44403 44388 18

44404 44388 18

44405 44388 18

44406 44388 18

44407 44388 18

44408 44388 18

45303 45300 19

45305 45300 19

45307 45300 19

45308 45300 19

45309 45300 19

45315 45300 19

45317 45300 19

45320 45300 19

45321 45300 19

45327 45300 19

45331 45330 20

45332 45330 20

45333 45330 20

45334 45330 20

45335 45330 20




Endoscopy Codes


45337 45330 20

45338 45330 20

45340 45330 20

45341 45330 20

45342 45330 20

45346 45330 20

45347 45330 20

45349 45330 20

45350 45330 20

45379 45378 21

45380 45378 21

45381 45378 21

45382 45378 21

45384 45378 21

45385 45378 21

45386 45378 21

45388 45378 21

45389 45378 21

45390 45378 21

45391 45378 21

45392 45378 21

45393 45378 21

45398 45378 21

46601 46600 22

46604 46600 22

46606 46600 22

46607 46600 22

46608 46600 22

46610 46600 22

46611 46600 22

46612 46600 22

46614 46600 22

46615 46600 22

47553 47552 23

47554 47552 23

47555 47552 23

47556 47552 23

49321 49320 24

49322 49320 24

49323 49320 24

49324 49320 24

49325 49320 24

50555 50551 25

50557 50551 25

50561 50551 25




Endoscopy Codes


50572 50570 26

50574 50570 26

50575 50570 26

50576 50570 26

50580 50570 26

50953 50951 27

50955 50951 27

50957 50951 27

50961 50951 27

50974 50970 28

50976 50970 28

52001 52000 29

52005 52000 29

52007 52000 29

52010 52000 29

52204 52000 29

52214 52000 29

52224 52000 29

52234 52000 29

52235 52000 29

52240 52000 29

52250 52000 29

52260 52000 29

52265 52000 29

52270 52000 29

52275 52000 29

52276 52000 29

52277 52000 29

52281 52000 29

52282 52000 29

52283 52000 29

52285 52000 29

52287 52000 29

52290 52000 29

52300 52000 29

52301 52000 29

52305 52000 29

52310 52000 29

52315 52000 29

52317 52000 29

52318 52000 29

52320 52000 29

52325 52000 29

52327 52000 29

52330 52000 29




Endoscopy Codes


52332 52000 29

52334 52000 29

52341 52000 29

52342 52000 29

52343 52000 29

52344 52000 29

52345 52351 30

52346 52351 30

52352 52351 30

52353 52351 30

52354 52351 30

52355 52351 30

52356 52351 30

52400 52000 29

52402 52000 29

52441 43235 14

57454 57452 31

57455 57452 31

57456 57452 31

57460 57452 31

57461 57452 31

58541 49320 24

58550 49320 24

58558 58555 32

58559 58555 32

58560 58555 32

58561 58555 32

58562 58555 32

58563 58555 32

58565 58555 32

58660 49320 24

58661 49320 24

58662 49320 24

58670 49320 24

58671 49320 24

58672 49320 24

58673 49320 24

66711 66710 33

CPT® is a registered trademark of the American Medical Association

REFERENCES The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy that was researched, developed and approved by UnitedHealthcare Reimbursement Policy Oversight Committee. [2020R0034C]

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services.

Centers for Medicare and Medicaid Services, CMS Manual System and other publications and services.



Centers for Medicare and Medicaid Services, Physician Fee Schedule (PFS) Relative Value Files.

Optum, The Essential RBRVS, 1st Quarter Update.

POLICY HISTORY/REVISION INFORMATION

Date Action/Description

07/01/2020

Overview • Removed language pertaining to Multiple Procedure Indicator 4, 5, 6, and 7

addressed in separate Reimbursement Policies

Reimbursement Guidelines • Added reference link to Question and Answer (Q&A) #6 pertaining to multiple

procedures reported with modifier 78 • Removed reference link to the Reimbursement Policy titled:

o Assistant Surgeon

o Co-Surgeon/Team Surgeon o Bilateral Procedures

• Added guidelines for Multiple Procedures for Bilateral Surgeries reported with modifiers LT and RT

• Removed modifier code descriptions

Questions and Answers (Q&A) • Updated A #6 pertaining to multiple procedures reported with modifier 78 • Updated A #7 pertaining to the Endoscopic Adjustment Rule

Applicable Codes • Updated list of Multiple Procedure Reduction Codes to reflect quarterly edits;

added HCPCS codes G2170 and G2171

Supporting Information • Archived previous policy version SURGERY 022.38 T0

517T 0518T 0519T 0520T 0524T 0525T 0526T 0527T 0530T 0531T 0532T 10005 10007 10009 10011 10021 10030 10035 10040 10060 10061 10080 10081 10120 10121 10140 10160 10180 11000 11004

11006 11010 11011 11012 11042 11043 11044 11055 11056 11057 11102 11104 11106 11200 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400 11401 11402

11403 11404 11406 11420 11421 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 11450 11451 11462 11463 11470 11471 11600 11601 11602 11603 11604 11606 11620 11621

11622 11623 11624 11626 11640 11641 11642 11643 11644 11646 11719 11730 11740 11750 11755 11760 11762 11765 11770 11771 11772 11900 11901 11920 11921 11950 11951 11952 64612

64615 64616 64617 64620 64630 64632 64633 64635 64640 64642 64644 64646 64647 64650 64653 64680 64681 64702 64704 64708 64712 64713 64714 64716 64718 64719 64721 64722 64726

64732 64734 64736 64738 64740 64742 64744 64746 64755 64760 64763 64766 64771 64772 64774 64776 64782 64784 64786 64788 64790 64792 64795 64802 64804 64809 64818 64820 64821

64822 64823 64831 64834 64835 64836 64840 64856 64857 64858 64861 64862 64864 64865 64866 64868 64885 64886 64890 64891 64892 64893 64895 64896 64897 64898 64905 64907 64910

64911 64912 64999 65091 65093 65101 65103 65105 65110 65112 65114 65125 65130 65135 65140 65150 65155 65175 65205 65210 65220 65222 65235 65260 65265 65270 65272 65273 65275

65280 65285 65286 65290 65400 65410 65420 65426 65430 65435 65436 65450 65600 65710 65730 65750 65755 65756 65770 65772 65775 65778 65779 65780 65781 65782 65785 65800 65810

65815 65820 65850 65855 65860 65865 65870 65875 65880 65900 65920 65930 66020 66030 66130 66150 66155 66160 66170 66172 66174 66175 66179 66180 66183 66184 66185 66225 66250

66500 66505 66600 66605 66625 66630 66635 66680 66682 66700 66710 66711 66720 66740 66761 66762 66770 66820 66821 66825 66830 66840 66850 66852 66920 66930 66940 66982 66983

66984 66985 66986 66999 67005 67010 67015 67025 67027 67028 67030 67031 67036 67039 67040 67041 67042 67043 67101 67105 67107 67108 67110 67113 67115 67120 67121 67141 67145

67208 67210 67218 67220 67221 67227 67228 67229 67250 67255 67299 67311 67312 67314 67316 67318 67343 67345 67346 67399 67400 67405 67412 67413 67414 67415 67420 67430 67440

67445 67450 67500 67505 67515 67550 67560 67570 67599 67700 67710 67715 67800 67801 67805 67808 67810 67820 67825 67830 67835 67840 67850 67875 67880 67882 67900 67901 67902

67903 67904 67906 67908 67909 67911 67912 67914 67915 67916 67917 67921 67922 67923 67924 67930 67935 67938 67950 67961 67966 67971 67973 67974 67975 67999 68020 68040 68100

68110 68115 68130 68135 68200 68320 68325 68326 68328 68330 68335 68340 68360 68362 68371 68399 68400 68420 68440 68500 68505 68510 68520 68525 68530 68540 68550 68700 68705

68720 68745 68750 68760 68761 68770 68801 68810 68811 68815 68816 68840 68850 68899 69000 69005 69020 69100 69105 69110 69120 69140 69145 69150 69155 69200 69205 69209 69210

69220 69222 69300 69310 69320 69399 69420 69421 69424 69433 69436 69440 69450 69501 69502 69505 69511 69530 69535 69540 69550 69552 69554 69601 69602 69603 69604 69605 69610

69620 69631 69632 69633 69635 69636 69637 69641 69642 69643 69644 69645 69646 69650 69660 69661 69662 69666 69667 69670 69676 69700 69711 69714 69715 69717 69718 69720 69725

69740 69745 69799 69801 69805 69806 69905 69910 69915 69930 69949 69950 69955 69960 69970 69979 78306 78320 78802 78803 78806 78807 92920 92924 92928 92933 92937 92941 92943

92975 92986 92987 92990 92992 92993 92997 93451 93452 93453 93454 93455 93456 93457 93458 93459 93460 93461 93505 93530 93531 93532 93533 93580 93581 93582 93583 93590 93591

93619 93620 93624 93640 93641 93642 93644 93650 93653 93654 93656 93660 96405 96406 96920 96921 96922 99170 G0104 G0105 G0121 G0127 G0168 G0186 G0268 G0276 G0341 G0342 G0343

G0412 G0413 G0414 G0415 G0429 G G0517 G0518

multiple procedures payment reduction (mppr) for medical and … · 2 days ago · multiple...

Documents