The Centers for Medicare and Medicaid Services (CMS) assigns each surgical procedure code indicators. The indicator designates the following, but not limited to:
Multiple surgery;
Bilateral surgery; and
Assistant at surgery.
The indicator is used in the reimbursement determination.
Surgical procedures that are components of or incidental to a primary procedure are not separately reimbursable.
Multiple surgeries are defined as separate procedures performed by the same physician during the same operative session.
Primary vs. secondary surgical procedure reimbursement is determined based on The Centers of Medicare and Medicaid (CMS) Resource Based Relative Value System (RBRVS) Relative Value Units (RVU). The procedure with the highest RVU is determined to be the primary surgical procedure and is reimbursed at 100% of the fee schedule allowable. Remaining surgical procedures are determined to be the secondary surgical procedure and reimbursed at 50% of the fee schedule allowable.
Bilateral surgeries are defined as procedures performed on both sides of the body during the same operative session. Bilateral procedures are reported on a single line of the claim with a unit of 1 and reimbursement for a bilateral procedure will be 150% of the fee schedule allowable.
Bilateral procedures may also be subject to multiple surgery reduction if billed in conjunction with other surgical procedures. Bilateral reimbursement is calculated prior to any applicable reduction that may apply.
Procedures that indicate 'bilateral' or 'unilateral' in the definition is not subject to bilateral pricing. Reimbursement would be subject to fee schedule allowable.
Procedures that are not considered bilateral are those related to organs that are considered midline (e.g., bladder, esophagus).
From time to time, surgical procedures may require more than one surgeon, a primary surgeon and an assistant surgeon. The indicator designated for the surgical code will indicate if it is never acceptable, always acceptable or sometimes acceptable. If assistant at surgery is 'sometimes' acceptable, documentation is required to accompany the claims for review and payment determination. Reimbursement for an assistant at surgery will be 16% of the fee schedule allowable.
MHP follows the medical criteria established by Medicare in determining reimbursement for assistant surgeons. If a procedure warrants the services of an Assistant Surgeon and is reimbursable by Medicare, it is also reimbursable by MHP. Conversely, any Assistant Surgeon service that is not covered by Medicare is not covered by MHP. Any expenses not considered appropriate are not billable to the member.
If Medicare requires the submission of medical records in order to determine the appropriateness of the charges, MHP requires records as well.
MHP covers and reimburses for microscopic assistance during surgery (e.g., a craniotomy or an extensive spinal surgery). Please bill with CPT code 69990.