This policy addresses reimbursement for multiple endoscopy procedures submitted on a CMS-1500 Claim Form as outlined below. This policy does not apply to Ambulatory Surgical Center facility fees billed on the CMS-1500 Claim Form or Outpatient Hospital facility fees billed on the UB-04 Claim Form.
The Centers for Medicare & Medicaid Services (CMS) applies special reimbursement rules for multiple endoscopic procedures performed for the same patient on the same day during the same session. BCBSND applies the same payment methodology for the same endoscopic procedures.
Endoscopic Base Procedure Code – Located on the CMS National Physician Fee Schedule (PFS) Relative Value Unit (RVU) File in the endoscopic base code field.
Endoscopic Family – All endoscopy codes that have the same endoscopic base procedure code.
Endoscopies subject to the multiple endoscopy reduction can be identified with an indicator of ‘3’ in the Multiple Procedure field on the CMS National Physician Fee Schedule (PFS) Relative Value Unit (RVU) File. The reduction occurs when an endoscopic procedure is billed with another endoscopic procedure in the same base endoscopy family.
Multiple endoscopy pricing rules will be applied to each base endoscopy family before ranking procedures performed on the same day, such as non-endoscopic procedures. When an endoscopic procedure is reported with only its base procedure code, no separate payment will be made for the base code. Payment for the base code is included in the payment for the other endoscopy. Additionally, when an endoscopic procedure is billed with procedures that are not endoscopies (i.e., surgical procedures), the Multiple Surgery Policy applies. After the multiple endoscopic reduction is ranked additional reimbursement policies will be ranked based on the service provided, for example Bilateral Procedure or Multiple Surgery Policy, etc.
Multiple Related Endoscopies (Same endoscopic base procedure)
- Determine the endoscopic procedure with the highest allowable rate and allow at 100%
- For each additional endoscopy within the family; allow the difference between the endoscopic base code’s allowed rate and the additional endoscopy code’s allowed rate
Two endoscopic procedures (Different endoscopic base procedures)
Four Endoscopies (Two different endoscopic base procedures)
- Follow the above calculation for determining each endoscopic family’s allowable amount
- Compare the total allowance for each endoscopic family
- The endoscopic family with the highest allowable amount will be allowable at 100%
- The remaining endoscopic family will be allowed at 50%