General Surgery Coding Alert

Question: The January 2001 General Surgery Coding Alert, p. 3, provides an example of the multiple endoscopy rule in which payment is calculated for a colonoscopic biopsy performed at the same time as a colonoscopic polypectomy. Payment for the secondary procedure (45380) is determined by subtracting the payment for the base procedure (45378).

This raises a further question: What is the rule when an upper endoscopy is performed at the same time as a colonoscopy? The colonoscopy is the higher reimbursed service. How is payment calculated for the upper endoscopy (there is no base code to be subtracted from it)?

Also, does your advice never to attach modifier -51 to multiple colonoscopy procedures pertain to the example of colonoscopy with upper endoscopy?

Edward S. Purvis, MD, FACS
South Boston, Va.

Answer: The multiple endoscopy rule does not apply to scope procedures performed in different endoscopy families, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill. Therefore, an upper endoscopy (43235, upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) performed at the same time as a colonoscopy (45378, colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) is considered a multiple procedure. Modifier -51 may or may not be used, depending on carrier preference (see Should Modifier -51 Be Used?).

To determine if the multiple endoscopy rule applies to two endoscopic procedures, consult your Medicare fee schedule, which includes the base code for any endoscopic procedure (if applicable) under heading AC. If the base codes are the same, the multiple endoscopy rule applies. Because upper GI endoscopies and colonoscopies have different base codes, the multiple endoscopy rule does not pertain to these procedures when performed together.

Finally, 43235 has no base code because it is itself a base code for more than a dozen upper GI endoscopy codes, including 43231-43232, 43239, 43241-43247, 43249-43251, 43255-43256 and 43258-43259.

Note: The Medicare fee schedule may be downloaded free from the HCFA Web site: www.hcfa.gov. For more information on using the Medicare fee schedule, see General Surgery Coding Alert, January and February 2001.