Wiki Multiple Endoscopy Procedures

[betty sanders]

The multiple endoscopy procedure rule states that if you bill out multiple codes in the same base code family the highest allowable rate will be paid at 100% (ex: 43245 and 43247). It also states that each additional same family code will be paid the difference between the endoscopic base code’s allowed rate and the additional endoscopy code’s allowed rate.

I have a terrible time getting paid for any additional code’s. We usually add the modifier 59 to the additional code but still don’t get paid (and no they aren’t bundling it into the initial code’s payment). Any help with this would be greatly appreciated. Also, Would anyone be willing to share an appeal letter regarding this issue?

 

[thomas7331]

I can try to help - I haven't done any appeals specifically for this situation, but I have audited payers for correct payment of these types of procedures. Are you billing for physician services or facility? If they are not bundling the code, what reason are they giving for not making an additional payment?

The multiple procedure payment rule you're citing above is specific to the Medicare physician fee schedule, though some other private payers may also use this rule. For your commercial payers, you'll have to look to your contracts and/or to those payers' published reimbursement policies. You'll only have a successful appeal if you can show that the payer is not adhering to your provider's contract, or is not paying correctly according to their policies. Hope this may help some but feel free to message me if you'd like me to look at any specific examples.

 

[betty sanders]

I can try to help - I haven't done any appeals specifically for this situation, but I have audited payers for correct payment of these types of procedures. Are you billing for physician services or facility? If they are not bundling the code, what reason are they giving for not making an additional payment?

The multiple procedure payment rule you're citing above is specific to the Medicare physician fee schedule, though some other private payers may also use this rule. For your commercial payers, you'll have to look to your contracts and/or to those payers' published reimbursement policies. You'll only have a successful appeal if you can show that the payer is not adhering to your provider's contract, or is not paying correctly according to their policies. Hope this may help some but feel free to message me if you'd like me to look at any specific examples.

Thanks so much for responding to my question. I am billing for Provider services. I just worked on a claim that is from Medicare and it's denying stating "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated". I billed a 45380 and 45385 on the same day and they paid 45385 but they are denying the 45380 with the denial above.

 

[thomas7331]

Thanks so much for responding to my question. I am billing for Provider services. I just worked on a claim that is from Medicare and it's denying stating "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated". I billed a 45380 and 45385 on the same day and they paid 45385 but they are denying the 45380 with the denial above.

That actually is a bundling denial - the biopsy procedure in 45380 is incidental the polyp removal in 45385. But under NCCI, these can be unbundled with a modifier if the biopsy was done at a separate site from the polyp procedure. A modifier on 45380 should get you payment for that procedure.