Outpatient Facility Coding Alert

Prepare yourself with these pointers for multiple-procedure and multiple-scope rules.

If your gastroenterologist performs a colonoscopy using multiple techniques to remove polyps in different parts of the colon, you have to check your physician’s documentation to determine the base endoscopic procedure before coding the service.

Look at these basic pointers to guide your multiple-endoscopy billing.

Understand the Concepts of “Family” and “Scope” 

If you want your claim to be successful, then you must know the reasons for applying the multiple-endoscopy rule and when to apply it.

Background: CMS devised the multiple-endoscopy method to avoid paying twice (or more) for “inclusive” services by reimbursing only a portion of any endoscopy performed at the same time as another endoscopy of the same basic type.

Watch for families: CPT® categorizes similar codes into so-called “families.” The basic procedure is designated the base or “parent” code, then all variants extend on the base code in the family. The text definitions for these so-called “child” codes have been worded to clearly show their relation to the base code. The definitions include any text in the parent code prior to the semicolon. 

For example, consider this 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
  
• 45334 -- ….with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
  
• 45338 -- … with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.
  

In this case, the parent code is 45330. The “child” codes are 45331, 45334, and 45338. In other words, 45331, 45334 and 45338 include all the work involved in 45330 plus something more.

Note: To keep your claims accurate, consult the most recent Medicare Physician Fee Schedule (MPFS) Relative Value File to confirm the endoscopic base codes within each family. This file is updated at least annually (and often several times per year), and can be downloaded from www.cms.gov/apps/physician-fee-schedule/documentation.aspx. 

Example 1: If your GI performs a diagnostic EGD (43235, Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) and then performs control of bleeding 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method), you will be able to report only 43255 because the endoscopic control of bleeding includes the work of a diagnostic endoscopy, 43235.

Because 43235 is a parent code, you can report it separately only if the surgeon did not provide any services in the 43235-43259 range. 

Multiple scopes: What if the GI performed multiple endoscopies during the same session that are not base codes in themselves but belong to same code family?

Here, Medicare applies a different “multiple-scope” rule and you are allowed to report both codes. However, Medicare only pays for the most extensive (i.e., highest-valued) scope at 100 percent value. Then, Medicare pays all additional scopes in the same family by subtracting the value of the base endoscopy and paying the difference.

Example 2: In the same session, the GI performs EGD with tumor removal by hot forceps (43250, Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) and follows it up with endoscopic mucosal resection in another location (43254, Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection). Because neither endoscope is a base procedure, you may report both procedures.

Medicare payers will reimburse the full value of the more extensive procedure (in this case, 43250). Medicare will also pay the value of the second scope minus the value of the base procedure. 

Be Confident With Non-Family Endoscopies

You only have to worry about the multiple-endoscopy rule if two or more endoscopies the physician performs are members of the same code family. In the above case, if the GI performed a 45331 and 45338 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 (43202, Esophagoscopy, flexible, transoral; with biopsy, single or multiple), you need not worry about the multiple-scope rule as both codes are billable.