Saturday, October 2, 2010

Payment for Multiple Procedures when performed in ASC

Payment for Multiple Procedures

Each surgical procedure has its own CPT code. When more than one surgical procedure is performed in the same operative session, special payment rules apply even if the services have the same CPT code number.
When the ASC performs multiple surgical procedures in the same operative session that are subject to the multiple procedure discount, Medicare will allow 100 percent of the highest paying surgical procedure on the claim plus allow 50 percent of the applicable payment rate(s) for the other ASC-covered surgical procedures subject to the multiple procedure discount that are furnished in the same session. The OPPS/ASC Final Rule for the relevant payment year specifies whether a surgical procedure is subject to multiple procedure discounting for that year. Final payment is subject to the usual copayment and deductible provision.
The multiple procedure payment reduction is the last pricing routine applied to applicable ASC procedure codes

In determining the ranking of procedures for application of the multiple procedure reduction, contractors shall use the lower of the billed charge or the ASC payment amount. The ASC surgical services billed with modifier 73 or 74 shall not be subjected to further pricing reductions (i.e., the multiple procedure price reduction rules do not apply). Payment for an ASC surgical procedure billed with modifier 74 may be subject to the multiple procedure discount if that surgical procedure is subject to the multiple procedure discount.
In these instances, final payment is subject to the usual copayment and deductible provisions.

Example of Multiple Surgery Pricing

This example should only be used to see how Medicare prices services under the multiple surgery pricing rules. The designated group identification and the allowed amounts are fictitious and should only be used as an example of multiple surgery pricing logic.

Procedure Code
Procedure Allowance
Medicare Allowable
(highest allows at 100%)
$714.64 x 50%=$357.32
(lesser allows at 50%)

Note: Providers are encouraged to research the ASC-covered procedure code list to identify those surgical procedures that will be subject to the special pricing logic. Providers are also encouraged to bill their reasonable and customary fees for all procedures, even for those surgical procedures that could be subject to the multiple procedure pricing logic. Providers should not reduce their billed amount even for those procedures that are believed to reduce due to the multiple surgery pricing logic. Reducing the billed amount could cause the provider to receive a smaller reimbursement than expected. Bill the reasonable and customary charge on all procedures and Medicare will make any pricing adjustments during the claim processing phases.

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