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Medicare Compliance & Reimbursement

CODING COACH:

Keep Scope Coding 'In The Family' To Avoid Errors

Published on Fri Feb 27, 2009

Are you missing out on hundreds? Now's the time to find out.

Coding scope procedures, such as colonoscopies and anoscopies, is commonplace in a surgery practice. But are you sure you're capturing every dollar your physicians deserve when they perform multiple scope procedures in one surgical session? There are times when you can report multiple scope procedures together, but if you don't know what they are you could be leaving money on the table.

Check Parent Codes

Colonoscopies, small bowel endoscopies, and anoscopies are all endoscopic procedures. The first question you need to ask when coding multiple endoscopic procedures during the same surgical session is:Are the endoscopies the surgeon performed in the same code "family"?

Pointer: If the answer is yes, the multiple-scope rule specifies that you cannot report the base, or "parent,"code separately with a more extensive endoscopy in that same code family.

Example: Your general surgeon performs a diagnostic 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]), followed by a colonoscopy and biopsy (45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple). Report only 45380 because that code already includes the work described by the diagnostic colonoscopy code (45378). In other words, 45378 is the "parent" code and you should not report it separately.

Note: Most private payers also follow the multiple endoscopy rule, says Jill Young, CPC, CEDC, CIMC, of Young Medical Consulting in East Lansing, Mich. Always check your payer's guidelines to be sure. "Ask them, or bill a few claims to see how they pay," Young says.

Don't Double Dip

You should always consider a diagnostic endoscopy as part of any surgical endoscopic procedure your surgeon performs. When the surgeon performs a diagnostic endoscopic procedure followed by a surgical scope procedure, you may report only the surgical procedure, regardless of whether the results of the diagnostic scope prompted the surgical scope.

In other words, when your surgeon performs multiple endoscopic procedures from the same family during the same encounter, the base or parent code (usually the diagnostic procedure) is included within the more extensive same-family procedure codes.

"The CPT guidelines state: 'Surgical endoscopy always includes diagnostic endoscopy,'" says Amy Carroll, CGSC, coding manager at The Coding Source in Los Angeles, Calif. "This statement precedes codes 45300, 44360, 43200, and so on."

The national Correct Coding Initiative (CCI) bundles reflect this rule, Young adds.

"The CCI guidelines, which can be found at www.cms.hhs.gov/NationalCorrectCodInitEd, are full of valuable information regarding coding guidelines for endoscopic procedures," agrees Carroll. "The base code (e.g., 45378) is designated a 'separate procedure' per CPT and not separately billable when a more extensive procedure is performed. When you check the CCI edits,the base code is bundled into the more extensive procedure in the same family."

Rule of thumb: With endoscopic procedures that have the same base code, you won't receive full payment for each of the endoscopic codes. The multiplescope 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 from the full fee of each additional endoscopic procedure and paying the difference.

Remember: Multiple procedure fee reductions always apply, regardless of a parent code. This means that you should sort the procedures on your claim in order from highest to lowest relative value units (RVUs). The payer then reimburses the highest-ranked procedure at 100 percent and any additional surgical procedures at 50 percent.

Reasoning: Payers include the value of the family base code in each code in the family. When the physician performs multiple procedures from the same family in one session, the payer is not going to reimburse you multiple times for the value of the base code.

Exception: If the surgeon performs a diagnostic endoscopy and, as a direct result of his findings, determines the need for an open surgical procedure, you may report the diagnostic endoscopy separately. CMS guidelines, as outlined in CCI, specifically state that if the surgeon performs an endoscopy for an initial diagnosis on the same day as the open procedure, you may report the endoscopy separately.

The CCI overview/guidelines, Chapter 6, state, "In the case where the endoscopic procedure is performed as a diagnostic procedure upon which the decision to perform a more extensive [open] procedure is made, the endoscopic procedure maybe separately reported," Carroll points out.

For Medicare payers, you should append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the open procedure to indicate that the diagnostic endoscopy and the open surgical service are staged or planned.

Submit All Non-Parent Codes

Your surgeon may perform two endoscopic procedures in the same session whose codes are not from the same family and have different base codes. The multiple-endoscopy rule applies only if your physician performs two or more endoscopies from the same code family. If he performs two endoscopic procedures from separate code families, you don't need to worry about this rule.

In such cases, when you're coding two or more procedures from different families and different base procedure codes, you may report both codes. Your payer may impose a multiple-procedure payment reduction on the second (and any subsequent) scope, however.

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