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Coverage for Multiple Surgical Procedures

Coverage for Multiple Surgical Procedures

When a surgery involves more than one surgical procedure covered under a customer's plan, reimbursement policies apply.

Reimbursement Policy

Multiple Procedures

Procedures performed during the same operative session by the same provider (known as "multiple procedures") are reimbursed following these guidelines:

  • 100% allowable for major procedure, or first surgical procedure
  • 50% allowable for all other procedures

Bilateral Procedures

Procedures requiring a separate incision performed during the same operative session (known as "bilateral procedures") are reimbursed following these guidelines:

  • 100% allowable for major procedures, or first surgical procedure
  • 50% allowable for all other procedures

Exclusions

  • This policy may not apply to facility charges.
  • This policy does not apply to procedures deemed to be Modifier 51-exempt. A Modifier-51 is used to indicate the subsequent surgeries/procedure(s) that are performed during a single session.

Quick Tips

  • Assistant surgeon fees are also subject to multiple procedure policy. Participating providers cannot balance bill customers for charges in excess of Cigna 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 Cigna's Clean Claim Requirements before submitting your claim for payment.