Endoscopic Multiple Procedure Policy

ngastroent

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I've got a Medicare replacement plan who recouped several claims stating an EGD and colonoscopy shouldn't both be paid, which we know if not true as they've been classified as separate systems. Does anyone know exactly where to find that wording on CMS? I've searched enough I'm starting to go insane not finding that wording to prove that's not the case to appeal with. Being it's a replacement plan, they just follow Medicare's guidelines so I know it's not in a contract with the plan itself.
 

nickelclaw

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Hello, sounds like the EGD may be missing a modifier. Below is the NCCI policy for digestive system:

6. A “scout” endoscopy to assess anatomic landmarks or assess extent of disease preceding another surgical procedure at the same patient encounter is not separately reportable. However, an endoscopic procedure for diagnostic purposes to decide whether a more extensive open procedure needs to be performed is separately reportable. In the latter situation, modifier 58 may be used to indicate that the diagnostic endoscopy and more extensive open procedure were staged procedures. If an endoscopic procedure is performed at the same patient encounter as a non-endoscopic procedure to ensure no intraoperative injury occurred or verify the procedure was performed correctly, the endoscopic procedure is not separately reportable with the non-endoscopic procedure.
 

thomas7331

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I've got a Medicare replacement plan who recouped several claims stating an EGD and colonoscopy shouldn't both be paid, which we know if not true as they've been classified as separate systems. Does anyone know exactly where to find that wording on CMS? I've searched enough I'm starting to go insane not finding that wording to prove that's not the case to appeal with. Being it's a replacement plan, they just follow Medicare's guidelines so I know it's not in a contract with the plan itself.
There's no such wording from CMS. You're correct that since these two procedures are done with different scopes, there is no overlap or bundling issue. It's very common to perform an EGD and a colonoscopy at the same session (I've had this done myself, actually) and no reason these should not both be paid, unless there is a medical necessity or coverage issue with one of them. Are they recouping the entire payment, or is it just a partial recovery to account for a multiple procedure reduction? This sounds like an error on the payer's part to me, and something you should push back on.
 

ngastroent

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There's no such wording from CMS. You're correct that since these two procedures are done with different scopes, there is no overlap or bundling issue. It's very common to perform an EGD and a colonoscopy at the same session (I've had this done myself, actually) and no reason these should not both be paid, unless there is a medical necessity or coverage issue with one of them. Are they recouping the entire payment, or is it just a partial recovery to account for a multiple procedure reduction? This sounds like an error on the payer's part to me, and something you should push back on.
That's what I'm thinking. I've been billing both for the gazillion years I've been here. So I do think they're wrong, but struggling to find the best document to submit with my appeal to prove they're considered in a separate "family" from the other procedure. Originally they paid 100% + 50% for the secondary, which was correct. They came back and recouped the 50% procedure, leaving the primary paid at 100%. Using your definition of these procedures using different scopes would be good to include
 

ngastroent

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Update to anyone who might look for this answer later, apparently I just needed to wait longer as I just received a new remit today where they repaid for both procedures. Glad I hadn't appealed yet
 
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