Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    QualChoice reimburses medically necessary surgical services. QualChoice applies multiple surgical procedures reduction when the same provider performs two or more surgical procedures on the same Member within the same operative session.

2)    This policy addresses the way in which these rules are applied to facility fees.

3)    If you are receiving care from a contracted network provider, this payment rule will not affect you except to reduce the amount of any coinsurance you may be required to pay.

4)    If you are receiving care from a non-contracted (out of network) provider, that provider may request that you pay amounts billed that were disallowed by QualChoice under the multiple procedure rules.

In general, the following rules will apply to multiple charges from the surgical facility, subject to the terms and condition of the facility contract:

1)    Gastrointestinal endoscopy is handled as follows:

a)    Any combination of codes for upper GI endoscopy (EGD or ERCP) will result in one payment for one surgical procedure, paid at the highest Ambulatory Surgery Center (ASC) rate applicable to any of the codes billed.

b)    Any combination of codes for lower GI endoscopy (flexible sigmoidoscopy or colonoscopy) will result in one payment for one surgical procedure, paid at the highest ASC rate applicable to any of the codes billed.

c)    Any combination of codes including both an upper GI endoscopy and a lower GI endoscopy will result in payment for two surgical procedures, the first paid at the full value of the highest ASC rate applicable to any of the codes billed, the second at ½ of the highest ASC rate applicable to any of the codes billed related to the opposite endoscopy (i.e.: only one upper GI endoscopy and one lower GI endoscopy procedure will be paid – one at full ASC rate and the other at ½ ASC rate).

2)    If multiple procedures are done through the same operating field and are related to one another (multiple biopsies during a bronchoscopy; multiple things done inside a joint during arthroscopy), we will allow the appropriate surgical facility fee for the primary procedure according to the facility contract. The second most important procedure will be paid at 50% and the others will be considered incidental and held to be included in the primary surgical fee.

3)    If multiple unrelated procedures are done in the same operative field (for example: distal pancreatectomy, splenectomy, repair of ureter, resection and repair of small bowel all due to a penetrating abdominal wound), reimbursement for the primary procedure will be at 100% of the applicable allowed case rate, reimbursement for each additional procedure will be calculated at 50% of the applicable allowed case rate.

4)    If a second procedure is performed and billed that is of a very minor nature compared to the primary procedure, or if it is performed “while we are here” or for the convenience of the surgeon and/or the patient, it will not be paid but will be held to be incidental and held to be included in that fee (for instance: appendectomy at the time of hysterectomy; removal of skin lesions at the time of laparotomy).

5)    If a second procedure requires a different or additional surgical set up, and is through a different operating field or incision, it will be paid as a secondary procedure; such procedures will continue to be paid at 50% for so long as they continue to qualify under this provision.

6)    In the case of a dispute about payment of multiple surgical charges to the facility, the following rules will apply:

a)    If the surgeon bills only one surgical procedure (where the facility bills for multiple procedures), the surgical procedure billed by the surgeon will be used to calculate the facility’s reimbursement.  Additional codes not appearing on the claim submitted by the surgeon will not be allowed unless approved by a QualChoice Medical Director.

b)    If QualChoice reviews the operative report to determine which surgical procedures were done, the assessment of a QualChoice Medical Director will determine the payment to both surgeon and facility.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.