Applying special rules for multiple Endoscopic procedures


Best answers
I have a question on the proper way to reimburse multiple endoscopic procedures within the same endo base family. For example, the following codes are billed together: 29805 fee schedule $200.00, 29807 fee schedule $310.02, 29819 fee schedule $275.12, 29820 fee schedule $270.13. All codes have the same base procedure of 29805. Per Medicare special rules for endo codes with an indicator of '3' would the correct processing of the codes be as follows:

29807= $310.02, 29819= $75.12, 29820= $70.13. Total reimbursement for those 4 codes: $455.27.

And if another nonrelated endoscopy or surgery with an indicator of '2' was performed on the same day and had a higher allowable amount, would that total of $455.27 be used to apply MSR? So $455.27*50%= $227.65 would be the total allowed for the set of codes sharing base code 29805?

Thanks for the help!


True Blue
Best answers
To your first question - your calculation of $455.27 is correct for the 3 codes, not 4 - I assume that's what you meant. The base code 29805 would be bundled unless it happened to be performed on the opposite shoulder, in which case the 50% rule would apply and give you $100.00 more.

For the second question, the answer should be yes, the 50% reduction would apply to all secondary procedures that fall into the category - the multiple procedure would apply first and then the multiple endoscopy via the same scope would also apply. However, this may vary by payer policy. In reality, I've found that the multiple endoscopy procedure reduction rules are not well understood by most payers, including the Medicare contractors, and the rules are not applied consistently so you'll probably find that the payments are all over the place in these types of situations.