Gastroenterology Coding Alert

Clear up your questions with an oil-change analogy

When your physician performs several endoscopies on the same day, you-ll need to know whether one of the endoscopes was a base procedure to bill these services correctly. Experts offer these basic pointers to guide your multiple-endoscopy billing.

Look to CPT for Scope -Families-

Before worrying about how to apply the multiple-endoscopy rule, you must first know why and when it applies.

The multiple-endoscopy rule is CMS- method to avoid paying twice (or more) for -inclusive- services by reimbursing only a portion of any endoscope performed at the same time as another endoscope of the same basic type, experts say.

Here's how the rule works: CPT divides groups of similar codes into so-called -families.- The first code (the base or -parent- code) describes the basic procedure. Following the base code, CPT lists any variants that -go beyond- the base code. The text definitions for these -child- codes are indented to show their relation to the parent code, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver. The definitions include any text in the parent code prior to the semicolon.

Example: Consider this partial code family:

- 45330--Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

- 45331--with biopsy, single or multiple

- 45332--with removal of foreign body

- 45333--with removal of tumor(s), polyp(s) or other lesions(s) by hot biopsy forceps or bipolar cautery.

In this case, 45331, 45332 and 45333 describe more extensive procedures than the base code, 45330, which they are listed under. In other words, 45331, 45332 and 45333 include all the work involved in 45330 plus something more.

Important: The multiple-endoscopy rule applies only if two or more endoscopies the physician performs are members of the same code family, says Joel V. Brill, MD, AGAF, chief medical officer at Predictive Health LLC in Phoenix. In other words, if the physician performs 45331 and 45333 during the same operative session, the multiple-scope rule applies. But if he performs 45331 and a scope from a different code family, such as esophagoscopy with biopsy (for example, 43202), you need not worry about the multiple-scope rule.
 
When a physician performs two endoscopic procedures from different families during the same session, then Medicare applies a different multiple-procedure rule. This is simply the multiple-scope rule, and this rule is different from the -family- multiple-scope rule. The average is normally 100 percent for the scope with the highest relative value and 50 percent for the second scope.

Always Include the -Base- Procedure

Suppose the physician has performed a diagnostic sigmoidoscopy (45330) plus sigmoidoscopy with control of bleeding (45334, ... with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]). How does the multiple-scope rule apply?

Remember: Follow-up codes always include the work involved in the base code, and surgical endoscopy always includes diagnostic endoscopy. Therefore, you would report only 45334 in this case. What about diagnostic sigmoidoscopy followed by single biopsy? Once again, you should report only the more extensive procedure--in this case, 45334.
 
No Base Procedure? Bill Both Scopes

If the physician performs two scopes in the same family, neither of which is the base procedure, you should report both codes. Therefore, if the physician performs biopsy with sigmoidoscopy followed by endoscopic removal of a foreign body, you would report both 45331 and 45332.

Watch Your Reimbursement

Under the multiple-endoscopy rule, CMS will pay the entire fee schedule amount for the highest-valued endoscopy in a given code family during the same operative session. CMS will reimburse any additional endoscopies in the same family by subtracting the value of the base endoscopy in that family and paying the difference.

The oil-change analogy: If this seems confusing, look at it another way. You take your car for service at the local dealer and see a sign reading:

Package 1: Oil change--$15

Package 2: Oil change and tire rotation--$25

Package 3: Oil change and replace wiper blades--$30

You order Package 3 and ask to have the tires rotated in addition. But you would not want to pay a full $25 for Package 2 in addition to the $30 for Package 3. Why pay for the oil change twice? Rather, you would expect to pay the $30 for Package 3 plus the difference between the cost of an oil change alone and the cost of an oil change with tire rotation, for a total of $40 ($30 for oil change and new wipers + [$25 for oil change and tire rotation - $15 for the cost of the -extra- oil change] = $40).

The situation works the same way when payers determine reimbursement for endoscopies. Because every endoscope in a given code family includes the -base- procedure, why pay for that portion of each procedure more than once?

For example, the physician performs sigmoidoscopy with tumor removal by hot forceps (45333), followed by polyp removal by snare technique (45338). CMS will pay for the full value of the more extensive procedure (in this case, 45338, with 7.90 relative value units [RVUs]), plus the value of the second scope minus the value of the base procedure (45333 is valued at 7.00 RVUs, from which you must subtract the 3.37 RVUs allotted for the family -base- code, 45330: 7.00 - 3.37 = 3.63 RVUs). Total payment for both scopes in this case would equal 11.53 RVUs (7.90 + 3.63). Note: These RVUs are for office-based procedures.

Check Out These Useful Links

Want to know more? You-ll find more insight on this topic by checking out the following links, provided by Brill:

- http://www.cms.hhs.gov/PRIT/PRITIP/itemdetail.asp?filterType=none&filterByDID=99&sortByDID=4&sortOrder=ascending&itemID=CMS063202&intNumPerPage=10

- https://www.noridianmedicare.com/macj3b/news/fees/docs/2004/utah/fs_endoscopy04.pdf

- http://www.lamedicare.com/provider/provnewslet/pdfformat/igspe2006c.pdf

- http://www.wellmark.com/products/providers/publications/Practitioner_Guide/GeneralSurgery.pdf

- http://www.kansasmedicare.com/part_B/faqs/multipleSurgery.htm (page 5).