Q&A: Different payments for the same code

August 15, 2008

Multiple procedures utilizing the same code can result in a lower rate of payment.

Q: When our surgical practice bills for procedures, we are, many times, paid at a lower rate than the published fee schedule. This can happen with the same CPT code - one time it will be paid at the correct rate and the next time it will be reduced. Can you tell me why?

A: There are two possible explanations. The first is that you have billed multiple procedures, with the second and third procedures reduced to a percentage of the fee schedule - i.e., the first procedure is allowed at 100 percent of the fee schedule, the second procedure is allowed at 50 percent of the fee schedule, and the third procedure is allowed at 25 percent of the fee schedule. The second reason may be where the procedure took place. If it was performed in an ambulatory surgical center, the "site of service" reduction would apply.