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§ 9789.16.5(c) Determining Maximum Payment for Multiple Surgeries

Summary

The Physician Fee Schedule reduces some surgical reimbursements when multiple surgical procedures are provided during the same surgery.

The codes listed below illustrate surgical cascading reimbursement. Per the regulation, reduced payments only apply to procedure codes which are assigned a Medicare Multi Procedure value of “2”.

Example: Procedure Codes 64718, 28307, and 22614

In the example, per the multiple surgical cascading reimbursement, 100% of the base maximum fee is reimbursed for the procedure code with the highest fee.

Procedure code 64718 has the highest base maximum fee of the three procedure codes, and therefore is reimbursed 100% of the fee.

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For the remaining codes, reimbursement is 50% of the base maximum fee. In the example below, reimbursement for procedure code 28307 is 50% of its base maximum fee.

Finally, reimbursement for procedure code 22614 is 100% of the base maximum fee. Procedure code 22614 is not subject to multiple procedure reductions, because the procedure code is assigned a Multiple Procedure value of zero. Remember: Only codes with a value of “2” are subject to surgical reductions.

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California Code of Regulations (CCR)

§ 9789.16.5(c) Determining Maximum Payment for Multiple Surgeries

Division of Workers’ Compensation Websites

Official Medical Fee Schedule

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