Urology Coding Alert

Question: Medicare has special rules for reimbursing multiple procedures when those procedures are endoscopies. All endoscopies include a diagnostic endoscopy and supposedly Medicare pays on the highest relative value at 100 percent. Payment for a second endoscopy is based on the difference between its relative value and the base codes value, and so it goes for the third procedure. It seems Medicare pays for only the highest (sometimes the lowest) and disallows all others. For example, 52260, 52204, 52005 used to diagnose interstitial cystitis. Is this correct and do you have any additional information?

Fay Kohler
Winchester, Tenn.

Answer: Medicares reimbursement guidelines for related endoscopies are as follows: The allowance is based upon the full value of the highest valued endoscopy plus the difference between the second highest endoscopy and the base endoscopy. A review of the Correct Coding Initiative indicates that CPT 52005 cannot be billed with 52260. It will, however, allow 52204 with a -59 modifier (distinct procedural service). It is important to note that this would have to take place during a different session, since taking a biopsy or tissue while performing another treatment in the same area is considered incidental to the procedure and is not to be billed separately. The value of the diagnostic or base colonoscopy is included in the value for both 52260 and 52204. In order to not pay twice for the same base endoscopy, the reimbursement from Medicare should be calculated as follows:

$205 = Full value of highest endoscopy 52260 at
$205 plus

$ 60 = The difference between the second highest
endoscopy, 52204 at $185, and the base endoscopy, 52000 at $125, equals: $265

Note: Your reimbursement will vary according to the fee scheduled for your area; the amounts indicated in this example are not actual Medicare allowables.

To file Participating physicians or nonparticipating physicians submitting an assigned claim:

On Line 1 of the claim form or equivalent record filed for electronic transmission, report the highest valued endoscopy 52260 at your full fee.

On Line 2, report the second higher endoscopy 52204 at the difference between your charge for the second highest endoscopy and your charge for the base endoscopy. Include the -59 modifier on this procedure.

To file Non-participating physicians submitting an unassigned claim.

On Line 1, report the highest valued endoscopy 52260 at 100 percent of the limiting charge.

On Line 2, report the second highest endoscopy at the difference between the limiting charge for the second highest endoscopy and the limiting charge for the base endoscopy.