Multiple operation rules

Multiple operation rules

For surgeons and assistant surgeons, where there are several billable surgical items on an invoice the appropriate Multiple Operation Rule will apply. Surgical items are all items in Group T8 of the CMBS. CESoft will apply the appropriate rule when you select a fund. CESoft also gives you the option to override the multiple operation rule for private billing. This should not be used for claims to insurers as it will generate an incorrect fee.

MBS Multiple Operation Rule

In most cases the MBS multi op rule applies, which calculates:
  1. 100% of the surgical item with the highest value,
  2. 50% of the second item,
  3. 25% for all subsequent items,
Exceptions are:
  1. Group T8 Subgroup 12 (amputations items 44325 - 44376) which are paid at 100% for each item
  2. Group T4 items (Caesarian Section and Interventional Obstetric items) which are paid at 100% for each item
See http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=TN.8.2

WorkCover insurers apply a mix of rules, where some items follow the MBS 100:50:25 rule and some follow the higher 100:75 rule. See below for details. 
NOTE: The 100:50:25 rule is applied separately to the 100:75 rule so where there's a mix of surgical and orthopaedic items on the same invoice, the first surgical item and the first orthopaedic item will both be paid at 100%

State Insurance Regulatory Authority (SIRA) New South Wales &
WorkCover Western Australia Multiple Operation Rule

SIRA NSW and WorkCover WA use these multiple operation rules based on the AMA fee schedule
  1. 100% for amputations, dislocations and fractures that require operative treatment,
  2. 100% for the first orthopaedic item (Group T8, subgroup 15 of the MBS, other than amputations, fractures and dislocations) or hand surgery item (Group T8, subgroup 14 of the MBS),
  3. 75% for all subsequent orthopaedic and hand surgery items,
  4. The MBS rule (100%:50%:25%) for all other surgical items.
NOTE: No benefit is payable for item 48415 when billed in combination with any shoulder surgery code (items 48900 – 48960).

WorkSafe Queensland Multiple Operation Rule

  1. 100% for amputations,
  2. 100% for the first orthopaedic item (Group T8, subgroup 15 of the MBS, other than amputations) or hand surgery item (Group T8, subgroup 14 of the MBS),
  3. 75% for all subsequent orthopaedic and hand surgery items,
  4. The MBS rule (100%:50%:25%) for all other surgical items. 

WorkSafe Victoria Multiple Operation Rule

WorkSafe Victoria uses these rules base on their published schedule
See https://www.worksafe.vic.gov.au/worksafe-spinal-surgery-billing-position-statement for specifics on spinal surgery items
  1. 100% for dislocations and fractures that require operative treatment,
  2. 100% for the first orthopaedic item (Group T8, subgroup 15 of the MBS, other than fractures and dislocations),
  3. 75% for all subsequent orthopaedic items,
  4. The MBS rule (100%:50%:25%) for all other surgical items.
NOTE: No benefit is payable for item 48415 when billed in combination with any shoulder surgery code (items 48900 – 48960).