Optimize Billing for Three or More Endoscopic Procedures Performed on the Same Day
Published on Mon May 01, 2000
Gastroenterologists may be familiar with how to code for two endoscopic procedures done on the same day by applying either the multiple surgeries or multiple endoscopic procedure payment rules and attaching the appropriate modifiers. When a gastroenterologist performs three or more endoscopic procedures on the same day, however, both payment rules may have to be used when preparing the claim.
Medicare uses two payment rules when reimbursing for multiple endoscopic procedures. To receive payment under either one of these rules, the claim and its documentation should reflect the medical necessity for doing each procedure, which is indicated by using the most appropriate ICD-9 code, says Pat Stout, CMC, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn. These rules are:
1. Standard Payment Rule for Multiple Surgeries. If two or more procedures with different endoscopic base codes are reported on the same day, the procedures should be listed on the claim in descending order according to their relative value units (RVUs). The procedure that has the highest RVU will be reimbursed at full value. Medicare will reimburse the other procedures at 50 percent of the value of their usual fee.
Because these procedures have different endoscopic base codes, they are referred to as being from unrelated endoscopic families.
The Medicare Carriers Manual states that the lesser-valued surgical procedures should be reported with modifier -51 (multiple procedures). But this is not required by all local Medicare payers or commercial insurance companies. (For more on this, see Increase Reimbursement with Correct Modifiers and ICD-9 Codes on page 19 of the March 2000 Gastroenterology Coding Alert.)
2. Special Payment Rule for Multiple Endoscopies. If two or more endoscopic procedures with the same endoscopic base code are reported on the same day, the procedures should be listed on the claim in descending order according to their RVUs. Reimbursement will include the full value of the procedure with the highest RVU, plus the difference between the value of the other procedures and their endoscopic base codes.
Because these procedures have the same endoscopic base code, they are referred to as being from related endoscopic families. Multiple procedures from related endoscopic families require the use of modifier -59 (distinct procedural service) if the procedures are bundled together in the Correct Coding Initiative (CCI). The Medicare Carriers Manual states that modifier -51 should be used if the procedures are not bundled. But this may not be a requirement of all local payers.
Related and Unrelated Procedures on the Same Day
When related and unrelated endoscopic procedures are performed on the same day, both sets of payment rules must be applied. The Medicare Carriers Manual states that when two sets of unrelated endoscopies are performed, the [...]
