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Q&A: Getting properly paid for complex procedures

Article

List the most complex (highest-fee) procedure first for reimbursement at 100 percent.

When we bill for multiple surgical services, we find that the insurer always picks the procedure with the lowest fee to reimburse at 100 percent, reducing other, more complex procedures by 50 or 75 percent, depending on the number of procedures performed. How can we get around this?

When submitting your claim, be certain to list the most complex (highest reimbursement) procedure first with the corresponding diagnosis. In addition, do not reduce your reimbursement for the second and third procedures, since the insurer will do that automatically. Make sure you are reporting the multiple-procedure modifier (–51) appropriately. Don't attach it to the primary procedure or to any "add-on" codes. Add-ons in CPT are indicated by a "+" next to the code.

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© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health