Multiple Procedure Reduction

The Multiple Procedure Reduction tool lets you define an expected payment reduction for claims with multiple procedure codes. For example, if a claim contains multiple surgery procedures, the secondary codes might be reimbursed at a lower percentage. To be eligible for this reduction, a line item must have its resources consumed prior to the multiple procedure reduction calculation.

You can apply this reduction to all line items with a Mod 51 modifier (multiple procedure code modifier) or you can enter a range of eligible procedure codes.

• The Apply to field lets you apply this reduction to all line items with a Mod 51 modifier (multiple procedure code modifier) or to a range of procedure codes. If you select All procedures in range, the From and To fields become active and allow you to enter a code range.
• The If not found in range field lets you specify a procedure lookup table to be considered for the multiple procedure reduction in addition to the code range you entered. To use this option, select the check box and then select a lookup table from the drop-down list. If a procedure code is found in the code range or the selected procedure lookup table, the reduction is applied.
  • To only consider procedures in a procedure lookup table, leave the From and To fields blank, select the If not found in range check box, and select a procedure lookup table.
  • To consider all procedures, leave the From and To fields blank and clear the If not found in range check box.
• The Apply exception rules using codes in field lets you specify a lookup table to be excluded from the multiple procedure reduction. Any codes found in the selected lookup table will not have the reduction applied to them.
• Once the Multiple Procedure Reduction tool identifies the procedures eligible for the reduction, it groups and sorts those procedures according to the following logic:
  • The procedures are grouped by dates of service. Only those procedures performed on the same day by the same physician are eligible for this reduction. For example, if two procedures on the claim qualify for the reduction, but have different dates of service, those claims are separated into two groups for the purpose of applying this reduction.
  • Each group is then divided into subgroups according to the following procedure modifiers with one subgroup for each:
    • AS – physician assistant services
    • 80 – assistant surgeon/surgical assistant services
    • 81 – minimum assistant surgeon/surgical assistant services
    • 82 – assistant surgeon when a qualified resident surgeon is not available
    • All other modifiers
  • If a procedure has more than one of the listed modifiers, it is grouped with the first subgroup it qualifies for (in the order listed above) and no others. For example, if a procedure has an 80 and 81 modifier, it is grouped the 80 subgroup only.
  • Each subgroup of procedures is then sorted by the method you select in the Sort by field, either Highest Reimbursement, Highest Charge, Highest RVU, or By the Order Billed on the Claim.
• Once the procedures are grouped and sorted, the multipliers you entered are applied according to the sort order. For example, if you sorted procedures by highest reimbursement, the first multiplier you entered is applied to the procedure with the highest reimbursement in each subgroup of procedures. The second multiplier is applied to the procedure with the second highest reimbursement, and so on.
• The value you enter for the multiplier indicates the percentage of reimbursement. For example, entering a multiplier of 50 reimburses the procedure at 50% of the repriced amount.
• If you select the Limit calculations to number of multipliers, procedures beyond the number of multipliers are priced to zero. For example, if the Multiple Procedure Reduction tool has identified, grouped, and sorted four procedures, but there are only two multipliers listed, the third and fourth procedures in the group are repriced to zero.
• Selecting the Virtually Adjust Modifier 50 check box automatically accounts for the various ways that bilateral procedures can be billed and ensures that these procedures are repriced correctly, regardless of the billing method on the claim.
• Clear any check box in the Apply Modifier Exemption To: section to include that modifier in multiple procedure reduction repricing. Modifiers 25, 27, 59, 76, and 77 are exempt from multiple procedure reduction, and the check box for each defaults to selected.
• Selecting the Apply bilateral proc rules to LT/RT codes check box applies bilateral procedures to codes with LT or RT modifiers.