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Multiple Surgery Pricing Per Session Methodology Update

October 24, 2013

Effective Feb.1, 2014, Blue Cross and Blue Shield of Texas (BCBSTX) will implement a change to our current “per operative session” methodology for Multiple Surgery Pricing.

The change is specific to Modifier-51 exempt codes and codes related to skin lesion removal and fracture care. Claim adjudication for these codes will remain exempt from “Multiple Surgery pricing methodology” and will not be subject to reduction if these codes are performed with other surgical procedures; however, with respect to codes which are subject to Multiple Surgery Pricing Methodology, Modifier-51 exempt codes and codes related to skin lesion removal and fracture care will be considered when identifying the primary surgical procedure (the procedure with the highest dollar allowance). If a Modifier-51 exempt code or a code related to skin lesion removal and fracture care is determined to be the primary surgical procedure, it will be adjudicated at 100% of the allowed amount and each subsequent surgical procedure performed will be adjudicated at 50% of the allowed amount. 

Note:  Add-on codes will continue to be exempt from Multiple Surgery pricing logic and will not be considered when determining primary procedures.