Adhere to the four strategies that every ortho coder needs to know. If your orthopedist performs several procedures during a knee arthroscopy on the same patient on the same day, you'll need to understand the multiple-scope rule to determine which procedures you can actually claim -- and get paid for. Important orthopedic exception: Follow these expert-approved tips to clinch your coding every time. 1. 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 Medicare's method to avoid paying twice (or more) for "inclusive" services by reimbursing only a portion of any scope performed at the same time as another scope of the same basic type. Here's how the rule works: In this case, 29806, 29807 and 29819 describe more extensive procedures than the family's base code, 29805, which they are listed under in CPT. In other words, 29806, 29807 and 29819 include all the work involved in 29805, plus something more. The multiple-scope rule applies only if two or more endoscopies the surgeon performs are members of the same code family. If the surgeon performs 29806 and 29807 during the same operative session, for instance, the multiple-scope rule applies. But if he performs a shoulder arthroscopy 29807 and a scope from a different code family, such as knee arthroscopy (for example, 29870, Arthroscopy, knee, diagnostic, with or without synovial biopsy [separate procedure]), you need not worry about the multiple-scope rule. In addition, you should not use modifier 51 (Multiple procedures) when the multiplescope rule applies. 2. Always Include the 'Base' Procedure Let's assume that the physician has performed a diagnostic shoulder arthroscopy (29805) plus shoulder arthroscopy for repair of SLAP lesion (29807). How does the multiple-scope rule apply? Remember: What about diagnostic shoulder arthroscopy followed by arthroscopic limited debridement? Once again, you should report only the more extensive procedure -- in this case, 29822 (Arthroscopy, shoulder, surgical; debridement, limited). 3. No Base Procedure? Bill Both Scopes If the surgeon performs two scopes in the same family, neither of which is the base procedure, you should report both codes. Therefore, if your orthopedist performs shoulder arthroscopy with foreign-body removal (29819) followed by shoulder arthroscopy for complete synovectomy, you would submit both 29819 and 29821 (... synovectomy, complete). Watch for CCI bundles: As a second example, CCI bundles many arthroscopic knee procedures, including removal of foreign body (29874), limited synovectomy (29875), debridement (29877) and lysis of adhesions (29884), into surgical knee arthroscopy with lateral release (29873). Best bet: 4. Watch Your Reimbursement Under the multiple-scope rule, Medicare will pay the entire fee schedule amount only for the highest-valued scope in a given code family during the same operative session. Medicare carriers will reimburse any additional scopes in the same family by subtracting the value of the base scope in that family and paying the difference. The oil-change analogy: 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: Medicare and other payers that follow Medicare guidelines will reimburse the full value of the more extensive procedure (in this case, 29880 with 9.45 work relative value units, based on the 2010 National Medicare Physician Fee Schedule Relative Value File), plus the value of the second scope minus the value of the base procedure (29873 has 6.24 work RVUs, from which you must subtract the 5.19 work RVUs allotted for the family "base" code, 29870: 6.24-5.19 = 1.05 RVUs). Total payment for both scopes in this case would equal 10.5 RVUs (9.45 +1.05). Check private payers: