Minor Surgery and Endoscopies - JE Part B
Minor Surgery and Endoscopies
Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.
A postoperative period of 10 days applies to some minor surgeries. If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the 10-day period, the major surgery is payable separately. Services by other physicians are not included in the global fee for a minor procedure except as otherwise excluded.
Endoscopy Families and Payment Rules
Medicare has special payment rules for multiple endoscopies performed on the same day during the same operative session. The chart below explains the process used for reimbursement when more than one endoscopy of the same family is performed on the same day. Medicare's payment rules are determined by classifying endoscopy procedures according to families. Each family has a base code and related codes that include the base procedure with additional components such as biopsy or polyp removal. These family codes are identified on the Medicare Physician Fee Schedule Indicator List with a '3' under the "M" column. The base code is listed in the "ENDO Base" column.
Related Endoscopy Family
Medicare allows highest valued endoscopy at 100% when endoscopies are in the same family.
- Find procedure with highest allowance
- Subsequent related endoscopies are reimbursed based on difference between base (or mother) code and subsequent codes
| CPT Code | Fee Schedule Allowable | Approved Amount | Rationale |
|---|---|---|---|
| 45385 | $374.56 | $374.56 | Code has highest fee schedule amount and allowed at 100% |
| 45380 | $285.98 | $30.58 | Base code (found on indicator list) = 45378 Allowed amount of 45378 = $255.40 Difference between 45380 and 45378 $285.98 - $255.40 = $30.58 |
Unrelated Endoscopies
Endoscopies not in same family, with different base codes, are reimbursed according to multiple surgery rules. Indicator in M column is 2 or 3.
- Find procedure with highest allowance
- Other procedures are allowed at 50%
| CPT Code | Fee Schedule Allowable | Approved Amount | Rationale |
|---|---|---|---|
| 29827 | $1,135.33 | $1,135.33 | Code has highest fee schedule amount and allowed at 100% |
| 29834 | $523.56 | $261.78 | Code allowed at 50% because in different family |
Two Sets of Unrelated Endoscopies
Codes from each set are from same family.
- Apply special endoscopy rule to each set separately
- Apply multiple surgery rules
Related Endoscopies - Set 1
| CPT Code | Fee Schedule Allowable | Approved Amount | Rationale |
|---|---|---|---|
| 43217 | $509.76 | $509.76 | Code has highest fee schedule amount and allowed at 100% |
| 43202 | $418.18 | $107.96 | Base code (found on indicator list) = 43200 Allowed amount of 43200 = $310.22 Difference between 43202 and 43200 $418.18 - $310.22 = $107.96 |
| Total | $617.72 | Add allowances for 43217 and 43202 $509.76 + $107.96 = $617.72 |
Related Endoscopies - Set 2 (Unrelated to Set 1)
| CPT Code | Fee Schedule Allowable | Approved Amount | Rationale |
|---|---|---|---|
| 46608 | $270.03 | $270.03 | Code has highest fee schedule amount and allowed at 100% |
| 46606 | $257.90 | $157.19 | Base code (found on indicator list) = 46600 Allowed amount of 46600 = $100.71 Difference between 46606 and 46600 $257.90 - $100.71 = $157.19 |
| Total | $427.22 | Add allowances for 46608 and 46606 $270.03 + $157.19 = $427.22 |
Processing of Unrelated Endoscopy Sets
| CPT Code | Approved Amount | Rationale |
|---|---|---|
| 43217, 43202 | $617.72 | Code set has highest fee schedule amount and allowed at 100% |
| 46608, 46606 | $213.61 | Code set allowed at 50% ($427.22 / 2) based on multiple surgery rules |
One Related and Two Unrelated Endoscopies
There are times when related and unrelated endoscopy sets are done on the same day.
- Organize related endoscopies into a group
- Organize unrelated endoscopies into a group
- Determine highest allowable amount in each group
- Apply multiple surgery rules
Related Endoscopies
| CPT Code | Fee Schedule Allowable | Approved Amount | Rationale |
|---|---|---|---|
| 45385 | $374.56 | $374.56 | Code has highest fee schedule amount and allowed at 100% |
| 45380 | $285.98 | $30.58 | Base code (found on indicator list) = 45378 Allowed amount of 45378 = $255.40 Difference between 45380 and 45378 $285.98 - $255.40 = $30.58 |
| Total | $405.14 | Add allowances for 45385 and 45380 $374.56 + $ 30.58 = $405.14 |
Unrelated Endoscopies
| CPT Code | Fee Schedule Allowable | Approved Amount | Rationale |
|---|---|---|---|
| 29835 | $540.03 | $540.03 | Code has highest fee schedule amount and allowed at 100% |
| 29843 | $522.12 | $261.06 | Code allowed at 50% ($522.12 / 2) based on multiple surgery rules |
| Total | $801.09 | Add allowances for 29835 and 29843 $540.03 + $261.06 = $801.09 |
Total of Related and Unrelated Endoscopies
| CPT Code | Approved Amount | Rationale |
|---|---|---|
| 45385, 45380 | $202.57 | Code set allowed at 50% ($405.14 / 2) based on multiple surgery rules |
| 29835, 29843 | $801.09 | Code set has highest fee schedule amount and allowed at 100% |
Endoscopy Families
Note: This list could change. Search for Code
| Base Code | Procedure Code |
|---|---|
| 29805 | 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29827, 29828 |
| 29830 | 29834, 29835, 29836, 29837, 29838 |
| 29840 | 29843, 29844, 29845, 29846, 29847 |
| 29860 | 29861, 29862, 29863, 29914, 29915, 29916 |
| 29870 | 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887 |
| 31505 | 31510, 31511, 31512, 31513 |
| 31525 | 31527, 31528, 31529, 31530, 31535, 31540, 31560, 31570 |
| 31526 | 31531, 31536, 31541, 31545, 31546, 31561, 31571 |
| 31575 | 31572, 31573, 31574, 31576, 31577, 31578, 31579 |
| 31622 | 31623, 31624, 31625, 31628, 31629, 31630, 31631, 31634, 31635, 31636, 31638, 31640, 31641, 31645, 31647, 31648, 31660, 31661 |
| 43200 | 43201, 43202, 43204, 43205, 43206, 43211, 43212, 43213, 43214, 43215, 43216, 43217, 43220, 43226, 43227, 43229, 43231, 43232 |
| 43235 | 43210, 43233, 43236, 43237, 43238, 43239, 43240, 43241, 43242, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43252, 43253, 43254, 43255, 43257, 43259, 43266, 43270, 52441 |
| 43191 | 43192, 43193, 43194, 43195, 43196 |
| 43197 | 43198 |
| 43260 | 43261, 43262, 43263, 43264, 43265, 43274, 43275, 43276, 43277, 43278 |
| 44360 | 44361, 44363, 44364, 44365, 44366, 44369, 44370, 44372, 44373 |
| 44376 | 44377, 44378, 44379 |
| 44380 | 44381, 44382, 44384 |
| 44388 | 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408 |
| 45300 | 45303, 45305, 45307, 45308, 45309, 45315, 45317, 45320, 45321, 45327 |
| 45330 | 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45340, 45341, 45342, 45346, 45347, 45349, 45350 |
| 45378 | 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392, 45393, 45398 |
| 46600 | 46601, 46604, 46606, 46607, 46608, 46610, 46611, 46612, 46614, 46615 |
| 47552 | 47553, 47554, 47555, 47556 |
| 49320 | 38570, 38571, 38572, 49321, 49322, 49323, 49324, 49325, 58541, 58550, 58660, 58661, 58662, 58670, 58671, 58672, 58673 |
| 50551 | 50555, 50557, 50561 |
| 50570 | 50572, 50574, 50575, 50576, 50580 |
| 50951 | 50953, 50955, 50957, 50961 |
| 50970 | 50974, 50976 |
| 52000 | 52001, 52005, 52007, 52010, 52204, 52214, 52224, 52234, 52235, 52240, 52250, 52260, 52265, 52270, 52275, 52276, 52277, 52281, 52282, 52283, 52285, 52287, 52290, 52300, 52301, 52305, 52310, 52315, 52317, 52318, 52320, 52325, 52327, 52330, 52332, 52334, 52341, 52342, 52343, 52344, 52400, 52402 |
| 52351 | 52345, 52346, 52352, 52353, 52354, 52355, 52356 |
| 57452 | 57454, 57455, 57456, 57460, 57461 |
| 58555 | 58558, 58559, 58560, 58561, 58562, 58563, 58565 |
| 66710 | 66711 |
