Name of Manual - Blue Cross and Blue Shield of Minnesota

Coding Policies and Guidelines (Coding)
General Claims
Processing
Information
Medical and Surgical
Supplies
Multiple Surgery
Guidelines
11-30
Scope Procedures
Our coding software makes the following assumptions when
determining payment for multiple scope procedures billed on the
same date of service:
A diagnostic scope is always incidental to a surgical scope.
A diagnostic scope with biopsy is always incidental to a
surgical scope.
A diagnostic scope with or without biopsy is always incidental
to an open surgical procedure in the same area.
A diagnostic scope rebundles to a diagnostic scope with biopsy
unless the code description makes the distinction with biopsy
vs. without biopsy.
CPT descriptions such as: complete vs. partial, with vs.
without, complex vs. simple, etc. means there are two mutually
exclusive codes for the procedures.
Medical and surgical supplies during an outpatient or physician
office visit are included as incidental to the E/M service or
procedure performed, and will not be separately reimbursed.
Multiple surgical procedures performed during the same operative
session are processed in accordance with Blue Cross multiple
surgical guidelines. These guidelines state the primary procedure is
determined as the highest billed charge and is reimbursed at 100%
of the fee schedule or billed amount, whichever is less. Secondary,
tertiary procedures, etc., again determined in order of billed
charge, are reimbursed at 50% of the fee schedule or billed
amount, whichever is less, regardless of separate site or incision.
In addition, procedures noted in CPT as “modifier –51 exempt” are
not subject to multiple surgery reductions.
Patient Billing Impact The patient is not responsible and must not be balance billed for
any procedures for which payment has been denied or reduced by
Blue Cross as the result of a coding edit. Edit denials are designed
to ensure appropriate coding and to assist in processing claims
accurately and consistently.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)