When a surgery involves more than one surgical procedure covered under a member's plan, multiple surgery reduction guidelines apply.
Note: State legislation and/or plan-specific language supersede Cigna HealthCare administrative guidelines.
Reimbursement Policy
Multiple procedures (modifier 51) - procedures performed during the same operative session by the same provider - are reimbursed:
- 100% allowable for major procedure, or first surgical procedure
- 50% allowable for all other procedures
Bilateral procedures (modifier 50) - procedures requiring a separate incision performed during the same operative session - are reimbursed:
- 100% allowable for major procedures, or first surgical procedure
- 50% allowable for all other procedures
- This policy may not apply to facility charges.
- This policy does not apply to procedures deemed to be Modifier 51-exempt.
- Assistant surgeon fees will be subject to multiple procedure policy.
- Participating providers cannot balance bill members for charges in excess of Cigna HealthCare allowable amounts.
- In some cases, the office visit is not separately reimbursable from the surgical code; the office visit copay does not apply.
- Always check "Clean" Claim Requirements before submitting your claim for payment.
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