Multiple Surgeries

Multiple Surgeries A. Part 203, Chapter 4 Rule 4.5.A, B is applicable for assistant surgeon, team surgeon, or co- surgeon services. B. Medicaid reimburses for the primary procedure at the highest reimbursement rate from the Medicaid Physician Fee Schedule. The primary surgical procedure must be billed first and other procedures must be billed on subsequent lines on the claim. C. Medicaid covers multiple surgical procedures performed by the same surgeon on the same patient and on the same date of service. The surgical procedures must be billed together on the same claim unless one (1) claim does not accommodate all of the procedures. D. For multiple surgeries performed on the same day, Medicaid covers the following: 1. Multiple surgical procedures performed at the same operative setting through a single opening are reimbursable at the Medicaid rate for the procedure with the greatest reimbursement. The additional surgeries through this same opening are not reimbursable unless a second surgical procedure adds significant time, risk, or complexity to patient care which Medicaid will reimburse as follows: a) The surgery with the greater Medicaid allowed amount will be reimbursed at the full amount. b) The second surgery will be reimbursed at one half the Medicaid allowance. c) The secondary procedure must be billed with the appropriate modifier. d) No additional benefits are paid toward incidental, mutually exclusive, or unbundled procedures. 2. Multiple surgical procedures performed at the same operative setting through separate incisions are covered as follows: a) The surgery with the greater Medicaid allowance amount will be reimbursed at the full amount. b) Secondary surgeries, will be paid at one half (1/2) of the Medicaid allowance. 1) These procedures must be identified with the appropriate modifier. 2) No benefits are provided for incidental, mutually exclusive, and unbundled procedures. 3. Secondary procedures must meet all of the following criteria: a) The secondary procedure is to correct a separate pathological condition, b) That pathological condition would have required intervention had an incision not already been present, and c) The degree of difficulty, operative time and risk were significantly increased by the secondary procedure. 4. If, after a surgical procedure has been completed, it becomes necessary to return and perform a subsequent surgical procedure that same day, Medicaid will cover the full- allowed amount for each surgical setting in accordance with multiple surgery criteria. E. Medicaid covers designated add on codes and other exempt codes from multiple surgery rules and coverage for multiple surgeries do not apply to these codes.