California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.16.5 - Surgery - Multiple Surgeries and Endoscopies

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) General
Multiple surgeries are separate procedures performed by a
						single physician or physicians in the same group practice on the same patient
						at the same operative session or on the same day for which separate payment may
						be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may
						participate in performing multiple surgeries on the same patient on the same
						day.
Multiple surgeries are distinguished from procedures that
						are components of or incidental to a primary procedure. These intra-operative
						services, incidental surgeries, or components of more major surgeries are not
						separately billable.
(b)
					 Billing Instructions
The following procedures apply when billing for multiple
						surgeries by the same physician on the same day.
* Report the more major surgical procedure without the
						multiple procedures modifier "-51."
* Report additional surgical procedures performed by the
						surgeon on the same day with modifier "-51."
There may be instances in which two or more physicians
						each perform distinctly different, unrelated surgeries on the same patient on
						the same day (e.g., in some multiple trauma cases). When this occurs, the
						payment adjustment rules for multiple surgeries may not be appropriate. In such
						cases, the physician does not use modifier "-51" unless one of the surgeons
						individually performs multiple surgeries.
(c) Determining Maximum Payment for Multiple
					 Surgeries
The Multiple Procedure ("Mult Proc") column of the
						National Physician Fee Schedule Relative Value File contains a "2" to indicate
						procedures that are subject to the surgery multiple procedure payment
						reduction.
If a procedure is performed on the same day as another
						procedure, base the payment on the lower of (a) the actual charge, or (b) the
						fee schedule amount for the procedure reduced by the applicable
						percentage.
Rank the procedures subject to the multiple surgery rule
						(indicator "2") in descending order by fee schedule amount and apply the
						appropriate reduction to this code:
(A) 100 percent of the fee schedule amount
					 for the highest valued procedure; and
(B) 50 percent of the fee schedule amount for
					 the second through the fifth highest valued procedures; or
(C) if more than five procedures with
					 indicator "2" are billed, pay for the first five according to (A) and (B) above
					 and pay "by report" for the sixth and subsequent procedures. Payment determined
					 on a "by report" basis should never be lower than 50 percent of the full
					 payment amount. Pay by the unit for services that are already reduced (e.g.
					 17003).
In cases of multiple interventional radiological
						procedures, both the radiology code and the primary surgical code are paid at
						100 percent of the fee schedule amount. The subsequent surgical procedures are
						paid at the standard multiple surgical percentages (50 percent, 50 percent, 50
						percent and 50 percent).