The Multiple Endoscopy Rule
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—that represents 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 (e.g., 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 additional work defined by the code descriptor.
A no fail way to find the endoscopic base code within each family is to consult the Medicare Physician Fee Schedule Relative Value File. The Relative Value 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 “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.
Applying the Multiple Scope Rule
The multiple scope rule requires that you 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 …with control of bleeding, any method, 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 …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) at full value. Medicare will also pay the value of the second scope, minus the value of the base procedure.
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) and esophagoscopy with biopsy (43202) 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)).