Blog/ Hospital billing
How are procedures at the same site billed?
Understand the CBHPM guidelines for paying for exams performed twice in the same encounter and learn to apply the 70% rate on the operating cost of additional items to ensure compliance in hospital audits
- By
- Rivio, Editorial team
- Published
- Reading time
- 2 minutes
In the day-to-day of medical and hospital billing, questions often arise when the same procedure is performed more than once in the same encounter. Situations such as a duplicate imaging exam at the same anatomical site often raise questions about the correct way to bill, especially since the Brazilian Hierarchical Classification of Medical Procedures (CBHPM) does not set an explicit rule for this scenario, leaving room for diverging interpretations between providers and health plans.
According to the CBHPM, when exams are performed in two or more different regions, the operating cost of the main or highest-tier exam must be paid at 100% of the set amount, while the additional exams receive 70% of that cost.
Although the text expressly mentions “different regions,” the technical understanding most commonly applied in billing is that this logic extends to situations in which the same procedure is performed more than once in the same encounter, even in the same anatomical region, as long as there is no specific provision to the contrary.
So, in cases such as performing an Arterial Color Doppler of the Upper Limb – Unilateral (CBHPM 40901459) twice at the same site, the most consistent interpretation is to pay one exam at 100% of the operating cost and the second at 70%.
Given the absence of an objective rule for this type of occurrence, the practical recommendation is to formally define this criterion in the contract or a contract amendment with the health plan, reducing the risk of denials and conflicting interpretations in the audit process.
