If a surgeon performs more than one procedure on the same patient on the same day, we will pay 100 percent of the global fee for the highest value procedure only and 50percent of the global fee for the second, third, fourth, and fifth procedure. Each procedure after the fifth procedure will require submission of documentation and special carrier review to determine the payment amount. This rule applies to surgery codes listed under rule 2 in the April 2002 Medicare Advisory . These codes should be submitted using the 51 modifier and if the 51 modifier is missing, the system will automatically add it to the rule 2 code with the lower fee schedule allowed amount.
Example: Mrs. Smith comes to your office for a tendon sheath injection (20550). She requires injections in two different anatomical sites. The first line is filed with no modifier and the next line is submitted using the 51 modifier as code 20550 falls under the multiple reduction rule. This means line one will allow $52.76 and line two will allow $26.38.
Some procedures are described in CPT as a second or subsequen t procedure, such as code 17003 for the second through fourteenth lesion and the payment level is already set at a reduced rate. These procedures will not be reduced further and therefore do not require a 51 modifier. These codes appear on the list of surgical codes with indicator zero in the surgical rule field. Please refer to your July 2002 Medicare Advisory for the most current list of surgical indicators.
