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Multiple Surgeries, Same Day
Avoid delays and denials by submitting procedures subject to multiple surgery payment rules on the same claim whenever possible.
Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed.
Steps to Follow:
- Determine whether the procedure is subject to multiple surgery rules by accessing the CMS Medicare Physician Fee Schedule Database at www.cms.hhs.gov/PFSlookup
- If the multsurg field for the surgical procedure indicates '2,' multiple surgery payment rules apply when performed on the same day as another procedure subject to multiple surgery payment rules
- The procedure with the highest fee schedule is paid at 100 percent
- Other procedures with indicator 2 are reduced by 50 percent
- If the multsurg field for the surgical procedure indicates '3,' special rules for multiple endoscopic procedures apply. These services should also be submitted on the same claim.
- If the second surgery on the same date is performed at a different time (e.g., due to complications that required a return trip to the operating room, or an unrelated surgical procedure), a modifier may be required. Refer to instructions in the Palmetto GBA Modifier Lookup Tool for instructions on submitting and documenting CPT modifiers 78 and 79.
- Some electronic billing software is set up to allow only 6 lines to be transmitted. Palmetto GBA can receive electronic claims with an unlimited number of lines. You may want to consider talking to your software vendor to increase the available number of lines per claim.
The reductions are applied regardless of whether the services are submitted on the same or separate claims. However, when services are submitted on separate claims, additional processing time is required and may delay payment or result in denial of the service(s).
Resources:
- Additional information regarding reimbursement calculations for multiple surgeries is available in the CMS Medicare Claims Processing Manual (PDF, 902 KB) (Pub. 100-04), chapter 12, Section 40.6
- The Palmetto GBA Modifier Lookup tool provides guidance on submitting and documenting CPT modifiers 78 and 79. Access the tool directly from the Ohio and West Virginia home pages:
- For more information about how Medicare reimburses surgical procedures, refer to the Physician/Supplier Guide chapter on the Global Surgery Package: