Check Your FESS Claims for Improper Payment Adjustments

Check Your FESS Claims for Improper Payment Adjustments

MACs may be applying the multiple endoscopy rule incorrectly.

In the 2020 Medicare Physician Fee Schedule (MPFS) Final Rule, the Centers for Medicare & Medicaid Services (CMS) finalized the proposal to apply the special rule for multiple endoscopic procedures to the family of functional endoscopic sinus surgery (FESS) codes.

Real-world Scenario

Practices are now getting remittance advice from their Medicare Administrative Contractor (MAC) for FESS. I was provided some information from a practice outside of Philadelphia, Pennsylvania, on the processing of payments by Novitas Solutions — MAC for jurisdictions L and H. Based on the remittance advice, it appears the MAC is incorrectly processing claims under the Multiple Endoscopy Rule. This is resulting in under-payments to the practice.
Two problems are evident. I am 100 percent sure the first is incorrect processing. The second, I am unsure if the carrier is incorrect, as this scenario was not addressed in the MPFS Final Rule; and this situation does not exist in other specialties two which the Multiple Endoscopy Rule has been applied, so there is no comparison that can be made.

Advocacy in Action

I have sent the below to the American Academy of Otolaryngology/Head and Neck Surgery (AAO/HNS), as well as leading otolaryngology surgeons — some who are members of the Board of Governors and all who are active with the AAO/HNS — for review, comment. and a plan for correction:

  1. Bilateral FESS surgeries are being performed. For example:

31276-50

31267-50

31254-50

My understanding is that payment for the second and third procedures for this surgery would be: (non-geographic adjusted Medicare fee)

(31267*150%) – 31231

($274.64*1.5) – $65.68 = $346.28

(31254*150%) – 31231

($251.91*1.5) – $65.68 = $312.19

But Novitas is returning remittances calculating the multiple endoscopy bilateral surgeries as follows:

(31267*150%) – (31231*150%)

($274.64*1.5) – ($65.68*1.5) = $313.44

(31254*150%) – (31231*150%)

($251.91*1.5) – ($65.68*1.5) = $279.35

I can understand why Novitas wants to apply the bilateral 150 percent to the base endoscopy code, but the base endoscopy code is described as nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure). There is no option in the MPFS to apply modifier 50 to the base endoscopy code and bill it as a bilateral code, being paid 150 percent of the fee schedule.
There is no comparison to the Multiple Endoscopy Rule applied to colonoscopy and upper endoscopy codes, as none of these services are ever performed bilaterally. Encountering a bilateral service is new to the Multiple Endoscopy Rule application. The Multiple Endoscopy Rule is predicated on the fact that the base endoscopy is included in the higher valued endoscopy. There is no billable bilateral diagnostic nasal endoscopy (31231-50), so the value of 31231-50 is not included in any of the higher valued FESS codes. Only the value of 31231, unilateral or bilateral, is included in the higher valued FESS codes. As a result, only $65.68 for multiple FESS procedures performed in a facility and $197.77 for multiple FESS procedures performed in the office (based on the non-geographic adjusted 2020 MPFS) can be subtracted from the higher value FESS, even if the FESS was bilateral and the fee was multiplied by 150 percent.

  1. When a non-endoscopic procedure, which is the highest-valued procedure, is performed with FESS surgeries, Novitas is applying both the Multiple Procedure Rule and the Multiple Endoscopy Rule to the multiple FESS. Below is an example of how Novitas is processing this type of surgery, applying both reductions:

30520

31255

31267

31287

Novitas is paying the above surgery as follows:

30520 at 100% = $665.49

31254 at 50% ($251.91*0.5) = $125.96

31287 (31287-31231) at 50% ($208.60 – $65.68)*0.5 = $114.34

31256 (31256-31231) at 50% ($186.58 – $65.68)*0.5 = $60.45

I am not sure how FESS should be paid when they are subservient to a higher-valued non-endoscopy code, but it does not appear to be appropriate to apply two reductions to these codes. It is my understanding that the endoscopic sinus surgery codes are to be paid under the Multiple Endoscopy Rule and not the Multiple Procedure Rule. I have not been able to find examples from the gastroenterology (GI) specialty for comparison because when endoscopic procedures are being performed other higher-valued open surgeries are not performed on the same day/same session. GI endoscopies are not even performed in operating rooms; they are performed in endoscopy suites.
Private payers (e.g., UnitedHealthcare) are following the MPFS and paying multiple FESS using the Multiple Endoscopy Rule. I think it is important that the proper processing of these surgeries and calculation of the fees are clarified to both MACs and private payers.
Whether your carrier is Novitas, or another carrier, considering the data used for this analysis is from remittance advice from Novitas for Pennsylvania, you may want to make sure your MAC and private payers (many are adopting the Multiple Endoscopy Rule) are processing and paying your claims properly. I hope the Academy can assist in getting this corrected and provide guidance on these two issues.
For reference, below is the Multiple Endoscopy Rule from the MPFS Final Rule for Calendar Year 2020:

Medicare Multiple Endoscopy Rule

Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in the Endobase field of this file. Apply the multiple endoscopy rules to a family before ranking the family with the other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure. Payment for the base procedure is included in the payment for the other endoscopy.

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Barbara Cobuzzi

About Has 105 Posts

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers. Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

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