Multiple Procedure Billing
More than one procedure may be performed on a member during the same operating session. We will normally uplift payment by a percentage of the most complex procedure and in exceptional circumstances it may be appropriate to pay for up to 100% of the fee for each procedure performed.
The following rules apply
- Where two procedures are carried out by the same operator during the same operating session, we will pay in addition up to 25% of the maximum for the most complex procedure
- Where three or more procedures are carried out during the same operating session, we will pay in addition up to 40% of the maximum for the most complex procedure
- Only in exceptional circumstances will we consider payment for more than three procedures
- Where a consultant assists another consultant, we will only pay the fee of the primary consultant
- Where two different procedures are performed on the same day but not in the same operating session, both procedures will be paid for at up to 100% of the eligible maximum
- Unbundled procedures will not be considered for payment in any circumstances
There are specific CCSD codes for procedures that are commonly or invariably performed bilaterally. If there is a code for the bilateral procedure (e.g. bilateral mastectomy), we will pay up to the fee maximum for that code only. Where there is no bilateral procedure code, the multiple rules apply.
A surgeon may anticipate that a particular procedure may be more complex than usual, or may find that they have spent longer in surgery than is usual, due to unforeseen circumstances or complications.
In this instance we are able to review the amount that we are prepared to pay if details of the complications or unusual circumstances are provided in advance of invoicing.