Learn Why and How to Apply the Multiple Endoscopy Rule
By G. J. Verhovshek, MA, CPC
You’ve probably heard of the “multiple procedure rule,” which reduces Medicare payment by 50 percent for the second and subsequent procedures provided to a single patient by the same physician on the same day. But did you know that a modified version of the multiple procedure rule may apply when reporting two or more endoscopic procedures?
All in the Family
CPT® and the Centers for Medicare & Medicaid Services (CMS) classify endoscopic procedure codes by “family,” where each family is comprised of related services. Each family has a “parent” code—called the endoscopic base code—representing the most basic version of that endoscopic service.
Usually, the base code is the first-listed code within a sequence of codes in CPT®. For example, consider this partial code family:
45300 Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
45303 with dilation (eg, balloon, guide wire, bougie)
45305 with biopsy, single or multiple
45307 with removal of foreign body
In this case, 45300 describes the most basic version of the service. Codes 45303, 45305, 45307, etc., include the work of 45300, plus any additional work in the code descriptor.
A no fail way to find the endoscopic base code within each family is to consult the most recent Medicare Physician Fee Schedule (MPFS) Relative Value File. This file is updated at least annually (and often several times per year), and can be downloaded from the CMS website.
The column labeled “ENDO BASE” will tell you the parent code for every endoscopic procedure. If there is no code in the “ENDO BASE” column, the code in column “A” is the base code (or the code in column “A” is not an endoscopic procedure). You can confirm the multiple-scope rule applies to a given code if you find a “3” in the “MULT PROC” column.
Apply Multiple Scope Rule
At its most basic, the multiple scope rule requires you to always bundle diagnostic endoscopy with any surgical endoscopy within the same family. For example, if a surgeon performs diagnostic sigmoidoscopy (45330 Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)) followed by sigmoidoscopy with control of bleeding (45334 Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)), you may report only 45334 because the endoscopic control of bleeding includes the work of a diagnostic endoscopy, 45330.
When a physician performs two endoscopic procedures in the same family, and neither procedure represents the base procedure, you may report both codes. Medicare payers will reimburse the most extensive (i.e., highest-valued) endoscopy at full value, and will reimburse any additional endoscopies in the same family by subtracting the value of the base endoscopy and paying the difference.
As an example, a surgeon performs sigmoidoscopy with tumor removal by hot forceps (45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery), followed by medically-necessary removal of polyps by snare technique (45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique). Because neither endoscope is the base procedure, you may report both procedures. Medicare will reimburse the more extensive procedure (45338, with 9.66 fully implemented non-facility relative value units (RVUs)) at full value. Medicare will also pay the value of the second scope, minus the value of the base procedure. In this case, the secondary scope, 45333, has 9.0 RVUs, from which we must subtract the 4.23 RVUs assigned to the endoscopic base code 45330.
No Relation = No Multiple Scope Deduction
The multiple endoscopy rule applies only when the physician performs two or more endoscopies in the same family. You don’t need to worry about the rule if the physician performs multiple endoscopies from different code families. For example, if a surgeon performs flexible sigmoidoscopy with single biopsy (45331 Sigmoidoscopy, flexible; with biopsy, single or multiple) and esophagoscopy with biopsy (43202 Esophagoscopy, rigid or flexible; with biopsy, single or multiple) during the same session, you may report each separately without payment reduction because these scopes are not part of the same code family (the base code for 45331 is 45330, while the base code for 43202 is 43200 Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)).
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.