Multiple Surgical Procedures

When two or more surgical procedures are performed on a patient by the same physician on the same date of service during the same operative session, professional claims will be processed using the edits listed below. If the following edits do not apply to the billed procedures, HMSA will pay plan benefits based on 100 percent of the eligible charge for the highest-valued procedure and 50 percent of the eligible charge for each subsequent procedure.

Claims Processing Edits

Incidental Procedures

An incidental procedure is a procedure done at the same time as a more complex primary procedure; however, the incidental procedure requires few additional physician resources and/or is clinically integral to the performance of the primary procedure. When this occurs, the incidental procedure will not be paid separately.

Example:

A claim is received with the following procedure codes:

• 47120
  Hepatectomy, resection of liver; partial lobectomy.
• 47371
  Laparoscopy, surgical, ablation of one or more liver tumor(s); cryosurgical.

HMSA will:
Process CPT code 47120 for benefit payment. CPT code 47371 will not be paid because it is considered incidental to the primary procedure.

Mutually Exclusive Procedures

Mutually exclusive procedures are two or more procedures that are usually not performed during the same patient encounter on the same date of service. Mutually exclusive procedures may also include different descriptions for the same type of procedure for which the physician should submit only one of the codes.

Example:

A claim is received with the following procedure codes:

• 40525
  Excision of lip; full thickness, reconstruction with local flap (e.g., Estlander or fan)
• 40520
  Excision of lip; V-excision with primary direct linear closure

HMSA will:
Pay the higher-valued procedure (40525) and deny payment for the other procedure because it is medically unlikely that both procedures would be performed on the same patient in the same operative session.

Claims Filing Information

Physicians are not required to include an operative report for most multiple surgical procedures except as listed below under the heading "Documentation". However, if five or more procedures are performed in the same operative session, an operative report is required so HMSA can consider the additional services for possible benefit payment.

When filing a claim for multiple surgeries, it is not necessary to indicate the primary procedure code and then add modifier code 51 to each additional procedure code. (If your computer software automatically adds modifier code 51 to subsequent procedures, you may continue to use the modifier. Use of the modifier will not affect the processing of your claim.) HMSA's claims processing system will process the claims, ordering the procedures so that the highest-valued procedure is processed first, followed by the subsequent procedures.

Documentation

Although an operative report is not needed to process most multiple surgical procedures, an operative report is still required for the following:

• Oral surgeries
• "By Report" procedures.
• "Unlisted" or "Miscellaneous" surgeries (e.g., CPT 19499).
• Surgeries that may be considered "cosmetic."
• Surgical repairs or procedures described by CPT as "intermediate," "complicated" or "complex."
• Surgeries represented with modifier codes 22, 53, 58, 62, or 77.

For more information see Claim Documentation Requirements.

Revision History