Multiple Procedures & Medicare

September 1, 2007

Do you have any evidence on how Medicare is supposed to pay for multiple procedures? I can’t seem to find any information on the CMS Web site.

Question: Do you have any evidence on how Medicare is supposed to pay for multiple procedures? I can’t seem to find any information on the CMS Web site.

Answer: What follows is the language from the Medicare Carrier’s Manual. You’ll want to make sure to use the -51 modifier on multiple surgeries. Also note that some surgeries are -51 exempt and will be bundled. You'll want to have a look in the 2007 CPT manual:
15038. Multiple surgeries (CPT modifier 51.)

A. General. When more than one surgical service is performed on the same patient, by the same physician, and on the same day:

  • The fee schedule amount for a second procedure is 50 percent of the fee schedule amount that would have been otherwise applicable for that procedure; and

  • The fee schedule amount for the third through fifth procedures is 50 percent of the fee schedule amount that would have been otherwise applicable for that procedure. Prior to January 1, 1995, the third through fifth procedures were paid at 25 percent of the fee schedule amount. Surgical procedures beyond the fifth are priced “by report” based on documentation of the services furnished. (See §4826.C for systems requirements related to payment for multiple surgeries.)

Sequence the procedures from the one with the highest regular fee schedule amount to the one with the lowest. In the case of interventional radiology procedures, see §15022.E.

B. Multiple Endoscopies. For multiple endoscopic procedures, use the full value of the highest valued endoscopy plus the difference between the next highest and the base endoscopy. For example, in the course of performing a fiberoptic colonoscopy (code 45378), a physician performs a biopsy (code 45380) and removes a polyp (code 45385). Both codes 45380 and 45385 contain the values of the base endoscopy, code 45378. Use the actual value of code 45385 plus the difference between codes 45380 and 45378. The endoscopic base codes are listed in the MFSDB. (See §4826.C.12 for additional information.)