Gastroenterology Coding Alert

Remember the multiple-scope rule when coding, checking reimbursement

If you-re reporting multiple endoscopic procedures during the same surgical session, you have to ask yourself an important question: Are the scopes the physician performed in the same code -family-?

If so, the multiple-scope rule specifies that you cannot report the base, or -parent,- code separately with more extensive scopes in the same family. In addition, you will face a fee reduction for multiple scopes in the same code family.

Include the Parent Code

You should always include a diagnostic scope in a surgical scope, according to CPT rules. As a more general statement, you should always include the base, or parent, endoscope in any more extensive endoscope(s) from the same family that the gastroenterologist provides on the same day, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, CodeRyte Inc. coding analyst and coding review teacher.

Example: The gastroenterologist performs a diagnostic sigmoidoscopy (45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), followed by sigmoidoscopy with control of bleeding (45334)
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In this case, you would report only the control of bleeding because 45334 already includes (bundles) the work described by 45330.

In other words: Because 45330 is a parent code, you would report it separately only if the gastroenterologist did not provide any services in the 45331-45345 range, Jandroep says. Note also that the descriptor for 45330 includes a -separate procedure- designation, meaning that you may not report this diagnostic scope separately with similar procedures.

If No Parent, Bill All Applicable Scopes

If the gastroenterologist performs two scopes in the same family, neither of which is the base procedure, you may report both codes, says Linda Martien, CPC, CPC-H, a coding consultant with National Healthcare Review Inc. in Woodland Hills, Calif.

Example: The gastroenterologist performs biopsy with sigmoidoscopy followed by endoscopic removal of a foreign body. In this case, neither scope is the base or parent procedure. Therefore, you would report both 45331 (... with biopsy, single or multiple) and 45332 (... with removal of foreign body).

Fee Schedule Can Help You Identify Base Codes

If you-re looking for a fast and easy way to identify endoscopic base codes, just consult the CMS Physician Fee Schedule, available as a free download from the CMS Web site http://www.cms.hhs.gov. Use the -search- function to find -PFS relative value files.-

After downloading the fee schedule, you can open an Excel file that lists all the CPT codes in numerical order. Column X of the fee schedule (labeled -Endo Base-) tells you the endoscopic base code for the code that you select from column A. If there is no code in column X, the code in column A is the base code (or the code in column A is not an endoscopic procedure at all).

Example: Select 44390 (Colonoscopy through stoma; with removal of foreign body) in column A and read column X. The endoscopic base code of 44390 is 44388 (... diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). By referencing the physician fee schedule, you can quickly see that 44388 is the endoscopic base code for all codes in the range 44389-44397.

For Multiple Scopes, Expect Reduced Payment

The multiple-scope rule specifies that Medicare will pay the entire fee schedule amount only for the highest-valued endoscopy in a given code family during the same operative session. Medicare will reimburse any additional endoscopies in the same family by subtracting the value of the base endoscopy and paying the difference, says Tara L. Conklin, CPC, an independent coding consultant in Wesley Chapel, Fla.

For example: The gastroenterologist performs sigmoidoscopy with tumor removal by hot forceps (45333), followed by removal of polyps by snare technique (45338) in the office. Because neither endoscope is the base procedure, you may report both.

Medicare payers will reimburse the full value of the more extensive procedure (in this case, 45338, with 5.23 physician work relative value units [RVUs]). Medicare will also pay the value of the second scope minus the value of the base procedure

Here's why: The payer has already reimbursed you once for the value of the family base code, 45330, when it paid you for 45338. The payer does not wish to reimburse for this again when reimbursing you for a same-session 45333.

Your payment total: The physician fee schedule values 45333 at 4.88 physician work RVUs, from which you must subtract the 2.28 RVUs allotted for the family base code, 45330. Total payment for both scopes in this case would equal 7.83 RVUs (5.23 for 45338 + [4.88 for 45333 minus 2.28 for 45330] = 7.83).
 
Different Families Mean No Special Billing

The multiple-endoscopy rule applies only if the gastroenterologist performs two or more endoscopies from the same code family, Martien says. But if he performs two scopes from separate code families, you needn't concern yourself with multiple-scope requirements.

Example: The gastroenterologist performs 45331 and esophagoscopy with biopsy (43202). Because these scopes are not part of the same code family, you may report them separately without special considerations.

Note: A different rule applies for multiple endoscopy procedures when you use the codes from different procedure families. Find out more in Gastroenterology Coding Alert's 2007 issues.