The Centers for Medicare and Medicaid Services (CMS) implemented special reimbursement rules for multiple endoscopic procedures performed for the same patient on the same day during the same session.  Medicare Advantage plans will also apply this same payment methodology for the same endoscopic procedures.

CMS identified thirty (30) endoscopic groups subject to this payment methodology.  Each grouping of related endoscopic procedures share the same “base code”.  A “base code” is a procedure whose allowance is included in the allowance for the other related endoscopic procedure codes within that particular grouping. 

The Procedure Code Attachment at the end of this policy provides a reference list of the endoscopic groups of procedure codes and their respective base codes that are subject to the multiple endoscopic payment reduction.  Base codes are listed on the attachment as “Endo Base Code”. 

Apply multiple endoscopy pricing rules to a group before ranking that group with other procedures performed on the same day (such as, when multiple endoscopies in the same group reported are reported on the same day as endoscopies from another group, or on the same day as a non-endoscopic procedure). 

If an endoscopic procedure is reported with only its base procedure code, do not pay separately for the base code.  Payment for the base code is included in the payment for the other endoscopy. 

If an endoscopic procedure is billed with a 51 modifier with other procedures that are not endoscopies (i.e., surgical procedures), the standard multiple surgery guidelines apply.

Examples

Multiple endoscopies in the same group

• Determine the highest paying procedure and allow payment at 100%
• For the other endoscopies, subtract the allowance for the group’s base code from the allowance for the related endoscopy and allow the difference

Multiple endoscopic procedures in different groups
For the first group

• Determine the allowance for the highest paying procedure and pay at 100%
• Determine the allowance for the other related endoscopic procedures by subtracting the allowance for the group’s base code from the allowance for the related endoscopy and pay the difference

For the other groups 

• Follow the same method of determining the allowance for each procedure reported within a group
• Finally, compare the total allowance for each group.  Pay the highest paying  group at 100% and the remaining groups at 50%

Multiple endoscopies in one group reported with one endoscopy from a different group
For the first group

• Determine the allowance for the highest paying procedure and pay at 100%
• Determine the allowance for the other related endoscopic procedures by subtracting the allowance for the ’s base code from the allowance for the related endoscopy and pay the difference

For the endoscopy in a different group

• Pay the endoscopy from the other  at 50 % of its allowance

One endoscopy in one group reported with one endoscopy from a different group

• Pay the highest paying procedure at 100% of the allowance
• Pay the other endoscopy at 50% of its allowance

Multiple endoscopies in one group and one is that group’s base code reported with multiple endoscopies in a different group
For the group that includes the base code

• Determine the allowance for the highest paying procedure and pay at 100%
• Deny the base code because the allowance for the base code is included in the allowance for the highest paying procedure

For the endoscopies in the other group(s)

• Determine the highest paying procedure and pay at 50%
• For the remaining endoscopies in that , subtract the allowance for the base code from the allowance for each endoscopy, and pay 50% of the difference

See Medicare Advantage Medical Policy Bulletin N-100 for information on Multiple Surgical Procedures.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Report the more major surgery or endoscopy procedure without the 51 modifier.  Report additional surgeries or endoscopy procedures performed by the physician on the same day with modifier 51.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-Line Manual Publication 100-04, Chapter 12, Section 40.6

CMS Transmittal 1574, CR 6013

Highmark Medicare Services On-Line Medicare Part B Reference Manual, chapter 22

Group 01 - Shoulder Arthroscopy/Surgery - Endo Base Procedure 29805