Florida Medicaid Provider Bulletin Summer 2008 Banner

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Physicians, ARNPs, PAs, CHDs, and Podiatrists

New Claims System for Multiple Surgery Billing

Multiple surgeries are separate procedures performed by a physician on the same patient during the same operative session or on the same day. Medicaid is programming the new claims processing system to price multiple surgery claims. This will reduce the requirements for paper processing in the future. Providers should bill surgical claims in the following manner to ensure correct reimbursement:
  • Bill all surgical procedures performed during the same operative session on the same claim;
  • Put the primary procedure with the highest Medicaid reimbursement on the first line;
  • Bill the secondary procedure with the second highest Medicaid reimbursement on the claim line directly under the primary procedure;
  • If the secondary surgical procedures are subject to Medicaid/Medicare multiple surgery pricing rules, use modifier 51;
  • If the procedure is an add-on code, or not subject to multiple surgery pricing use modifier 59, or no modifier. Do not use modifier 51;
  • Use modifier 62 in the first modifier field when billing co-surgeon claims; and
  • Use modifier 80 in the first modifier field when billing assistant surgeon claims.
Reimbursement for multiple surgery procedures for the same beneficiary, on the same day by the same treating provider, are priced using the following methodology:
  • 100% of the Medicaid fee for the procedure with the highest fee;
  • 50% of the Medicaid fee for the procedure with the second highest fee; and
  • 25% of the Medicaid fee for all remaining procedures that are subject to multiple surgery priding rules.
For example: If you are billing for a repair of a rotator cuff (Code 23412), a ligament release (Code 23415), and a claviculectomy (Code 23120), report the codes as follows:
  • 23412
  • 23415-51; and
  • 23120-51.
For questions regarding this information, contact your local Medicaid Area Office.