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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.

This image shows the MPFS Indicator List with the M column and ENDO Base columns highlighted.

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

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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

 

Last Updated Tue, 20 Nov 2018 14:03:23 +0000