Scope Out the Rules for Billing Multiple Endoscopies

Scope Out the Rules for Billing Multiple Endoscopies

Understand the Multiple Procedure Payment Reduction rule to help ensure accurate reimbursement.

If you’ve ever billed for multiple endoscopies performed on the same date of service to the same patient by the same provider and noticed a drastic reduction in the payment for the subsequent procedures, you’ve encountered the Multiple Procedure Payment Reduction (MPPR) rule. What’s confusing is that the rule changes depending on whether you’re billing the professional component (PC) or technical component (TC) and whether the procedures are related. In this article, we’ll make sense of it all by walking you through some examples for when the MPPR rule and the special rule for multiple endoscopies apply.

MPPR Methodology

The MPPR rule is applicable when the same physician (or physicians in same group) performs multiple surgeries on the same patient during the same session. In this instance, Medicare Administrative Contractors (MACs) will reimburse only the procedure with the highest relative value unit (RVU) at 100 percent of the Medicare Physician Fee Schedule (MPFS) amount and will reduce the payment for the subsequent procedures per the standard payment rules.

The rule also states that when two or more endoscopic procedures within the same “family” are performed by the same physician on the same patient during the same session, special rules apply. Any subsequent endoscopies in the same family are instead paid at a reduced amount that takes into account the RVUs for the base or “parent” procedure code.

The reason for this payment structure is that most endoscopic procedures include preoperative, intraoperative, and postoperative work, and insurance providers often consider preoperative and postoperative work as overlapping services in the case of multiple procedures.

How to Identify Base Procedure Codes

In the CPT® code book, procedures are classified based on family, and each family comprises related services. Within each family exists a parent code, or base code, which represents the simplest service. The base code is always the first listed code in the family.

For example:

43235    Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

43236   with directed submucosal injection(s), any substance

43239   with biopsy, single or multiple

In this case, 43235 is the base procedure code, which describes the basic version of the service. Codes 43236 and 43239 include the basic service of 43235 plus additional work. Another way to identify the base procedure code is to look up the multiple procedure indicators in the MPFS Relative Value files, which you can find on the Centers for Medicare & Medicaid Services (CMS) website.

CMS MPFS Multiple Procedure Indicators
2 –
Standard payment adjustment rules for multiple procedures apply. If the procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%)
3 –
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).

Multiple Endoscopy Procedures (Same Family)

Let’s walk through a scenario for a patient scheduled for a diagnostic colonoscopy performed in a facility. The provider performs cold forceps biopsy in the ascending colon (45380) and polypectomy using cold snare technique in the descending colon (45385). The base code for these two procedures is 45378 for the diagnostic colonoscopy. These two additional procedure codes are grouped within the same family, so the special reduction rule applies.

Table 1 shows the payment structure for these codes. Since 45385 has the highest RVU, it receives 100 percent payment of the allowed non-facility/facility price. The allowed amount for the second procedure (45380) is reduced. To calculate the new allowed amount for 45380, subtract the allowed amount of the base procedure ($191.87) from the allowed amount of the second procedure ($208.25). Per the special rules for multiple endoscopies, the insurance payment will be $16.38 for the second endoscopic procedure.

Multiple Endoscopy Procedures (Different Family)

Now, let’s turn to unrelated endoscopy procedures. When multiple unrelated endoscopies are performed on the same day on the same patient by the same physician (or physician group), the special rules for multiple endoscopies do not apply because the codes are not in same family. In this case, the procedures will be paid based on the standard multiple surgery reduction rules.

According to CMS’ MPFS Relative Value files, “If the procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%).”

Let’s look at the example in Table 2. If an endoscopy procedure is billed with another procedure that is not an endoscopy, then standard rules apply. Billing endoscopy procedure 45380 with 46200 (which is not an endoscopy procedure) falls under this rule. The facility payment for 46200 (the highest RVU) will be at 100 percent ($360.06), and 45380 will receive $104.12 (50 percent of $208.25).

Note: Append modifier 51 Multiple procedures to the additional surgical procedure code(s).

Multiple Endoscopy Procedures (Unrelated Endoscopies)

When two sets of unrelated endoscopies are billed (e.g., 45380 and 45386; 43251 and 43249), the special multiple endoscopy reduction rule applies to each series first and the standard multiple surgery rule second. Consider the total payment for each set of endoscopies as one service.

Let’s look at the example in Table 3. Payment for unrelated endoscopies is calculated by following these two steps:

1.  Apply Multiple Endoscopy Reduction rules:

45386 (highest RVU) 100 percent payment: $219.59

45380 (allowed amount minus allowed amount of family base procedure code 45378): $208.25 – $191.87 = $16.38

43251 (highest RVU) 100 percent payment: $203.64 (further deduction will apply)

43249 (allowed amount minus allowed amount of family base procedure code 43235): $159.60 – $127.67 = $31.93 (further deduction will apply)

2. Apply Multiple Surgery Rules:

43251 will be paid at 50 percent: $203.64/2 = $101.82

43249 will be paid at 50 percent: $31.93/2 = $15.96

Total payment: $219.59 + $16.38 + $101.82 + $15.96 = $353.75

No More Surprises

Now that you understand the MPPR rules, including the special rules for multiple endoscopies, you will be able to estimate reimbursement for subsequent endoscopy codes. This will save you a lot of time unnecessarily following up with payers or appealing claims that were paid appropriately.


Resources:

CMS MPFS RVU Files.

Medicare Claims Processing Manual, Ch. 12, §40.6.

Shruthi Sargur Ravindranath
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Shruthi Sargur Ravindranath, M.Sc, CPC, has more than 14 years of experience in medical coding and a master’s in zoology. She is associated with Vitalaxis, Inc., as senior coding manager. Ravindranath is a member of the Bangalore, India, local chapter. She is experienced in multiple specialties including E/M, gastroenterology, surgery, anesthesia, internal medicine, general surgery, and radiology.

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