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 [...]