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Multiple Endoscopy Services

Commercial Reimbursement Policy
Origination: 05/2024
Last Review: 11/2024

Description

Multiple endoscopy procedures are assigned a multiple procedure indicator of “3” by CMS.

Base procedure is the parent code of a group of procedures, identifying them as services in the “same family”.

Same group practice is defined as a physician and/or other qualified health care professional of the same specialty with the same Federal Tax ID number.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) allows professional reimbursement for multiple endoscopy services performed on the same day by the same provider or provider group, according to the criteria outlined in this policy. 

 

Reimbursement Guidelines

Multiple endoscopy procedures in the same family (sharing the same base procedure) will receive reduced allowed amounts when performed by the same provider or group practice on the same date of service.

Multiple Endoscopy Procedures (Same Family) on the Same Day

Reimbursement will be based on the following:

  • The primary procedure, indicated by the highest Relative Value Unit (RVU), will be reimbursed at 100%
  • Secondary procedure(s) will be reimbursed based on the procedure’s adjusted RVU (the RVU minus (-) the shared base procedure’s RVU).
  • No reimbursement will be made for the endoscopic base procedure.

Note: The multiple surgery reduction (MSR) does not apply to multiple endoscopy procedures in the same family. 

Multiple Endoscopy Procedures (Different Families) on the Same Day

Reimbursement will be based on the following:

  • For each endoscopy family, follow the multiple endoscopy rule above for multiple procedures reported within the same family.
  • The different endoscopy families are ranked in descending order by their cumulative values (i.e., the sum of the primary procedure’s RVU and secondary procedure(s)’ adjusted RVUs).
  • MSR is applied to the secondary procedure(s) within the secondary family(ies) (as indicated by their RVU ranking). Please see reimbursement policy “Multiple and Bilateral Surgery” for more information.

Multiple Endoscopy Procedures (Same Family) and Unrelated Procedure(s) on the Same Day

Reimbursement will be based on the following:

  • For each endoscopy family, follow the multiple endoscopy rule above for multiple procedures reported within the same family.
  • Procedures are ranked in descending order by RVUs/cumulative RVUs (for more information on cumulative RVUs, see different endoscopy family section above) MSR is applied to the secondary procedure(s) and/or secondary procedure(s) within the secondary family(ies), as indicated by their RVU ranking. Please see reimbursement policy “Multiple and Bilateral Surgery” for more information. 

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross NC web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Illustrative Examples

Scenario 1: Two Endoscopy Procedures with Same Base Code (Same Families)

43201 (5 RVUs) and 43202 (6 RVUs) are billed together. Both codes share the same base code of 43200 (2 RVUs). The higher valued code of 43202’s allowed amount remains unaffected at 6 RVUs. The lower valued code of 43201 would be calculated by taking the allowed amount of 43201 (5 RVUs) and subtracting the shared base code of 43200 (2 RVUs). The difference between 43201 and 43200 is the assigned final value of 43201 (3 RVUs). 9 RVUs would then be the total allowable.

43202 (6 RVUS) + 43201 Reduced by 43200 Base Code RVUs (5 RVUS – 2 RVUS = 3 RVUS) = 9 RVUs allowed.

Scenario 2: Two Endoscopy Procedures with Different Base Codes (Different Families)

43232 (4 RVUs) and 43233 (6 RVUs) are billed together. Both codes have different base codes of 43200 and 43235, respectively. Therefore, multiple endoscopy reduction would not apply. Multiple procedure rules (50% reduction) would still apply to 43232 (the lower valued code). 8 RVUs would then be the total allowable.

43233 (6 RVUs) + 43233 reduced by 50% (4 RVUs * 50% = 2 RVUs) = 8 RVUs allowed.

Scenario 3: Two Endoscopy Procedures with Same Base Code (Same Family) + One Endoscopy Procedure with Different Base Code (Different Family)

43248 (5 RVUs) and 43249 (12 RVUs) are billed along with 44361 (10 RVUs). 43248 and 43249 share the same base code of 43235 (3 RVUs). The allowed amount of the higher valued code, 43249, remains at 12 RVUs. The lower valued code of 43248 would be calculated by taking the allowed amount of 43248 (5 RVUs) and subtracting the shared base code of 43235 (3 RVUs). The difference between 43248 and 43235 is the assigned final value of 43248 (2 RVUs). The cumulative value of 43248 and 43249, (14 RVUs), is then weighted against the value of unrelated procedure 44360 (10 RVUs) for multiple procedure reduction rules to apply. Multiple procedure rules (50% reduction) would apply to 44361 (the lower valued code) leaving 5 RVUs. The total claim allowable is 19 RVUs.

43249 (12 RVUs) + 43248 Reduced by 43235 Base Code RVUs (5 RVUs – 3 RVUs = 2 RVUs) = 14 RVUs base minus lowest RVU

Cumulative RVUs for related procedures (14 RVUs) + 44361 Reduced by 50% (10 RVUs * 50% = 5 RVUs) = 19 RVUs allowed. MSPR applied.

Scenario 4: Two Endoscopy Procedures with Same Base Code (Same Family) + One Non-Endoscopy Procedure

43248 (5 RVUs) and 43249 (6 RVUs) are billed along with 47605 (10 RVUs). 43248 and 43249 share the same base code of 43235 (3 RVUs). The allowed amount of the higher valued code, 43249, remains at 6 RVUs. The lower valued code of 43248 would be calculated by taking the allowed amount of 43248 (5 RVUs) and subtracting the shared base code of 43235 (3 RVUs). The difference between 43248 and 43235 is the assigned final value of 43248 (2 RVUs). The cumulative value of 43248 and 43249, (8 RVUs), is then weighted against the value of unrelated procedure 47605 (10 RVUs) for multiple procedure reduction rules to apply. Multiple procedure rules (50% reduction) would apply to the cumulative RVUs of 43248 & 43249 (the lower valued code) leaving 4 RVUs. The total claim allowable is 14 RVUs.

43249 (6 RVUs) + 43248 Reduced by 43235 Base Code RVUs (5 RVUs – 3 RVUs = 2 RVUs) = 8 RVUs

47605 (10 RVUs) + Reduced Cumulative RVUs for related procedures by 50% (8 RVUs * 50% = 4 RVUs) = 14
RVUs allowed

Related Policy

Bundling Guidelines

Multiple and BilateralSurgery

References

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Centers for Medicare and Medicaid Services, Physician Fee Schedule (PFS)
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value- Files

History

05/01/2024 New policy developed. RPOC approved. Notification on 5/01/2024 for effective date 7/10/2024. (tlc)

11/1/2024 Clarification to the definition of same group practice. No change to policy intent. (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Blue Cross and/or Blue Shield Plan Members who seek care from the NC service area). This policy does not apply to Blue Cross NC Members who seek care in other states.

This policy relates only to the services and/or supplies described herein. Please refer to the applicable Member’s Benefit Booklet for availability of benefits. Member’s benefits may vary according to benefit design; therefore, Member benefit language should be reviewed before applying the terms of this policy. 

Disclosures:

Reimbursement policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and Blue Cross NC reserves the right to review and revise its medical and reimbursement policies periodically.