Multiple Endoscopy Procedures

I. Payment Rules

HMSA adopted Medicare rules for the payment of multiple endoscopy procedures performed on the same day, during the same operative session. Medicare's payment rules are determined by classifying endoscopy procedures according to families. Each family has a base code (the simplest endoscopy service within the family) and related codes that include the base procedure with additional components such as biopsy or polyp removal.

II. Calculation of the Eligible Charge

1. Related Endoscopies
   When multiple endoscopy procedures from the same family are billed, plan benefits are applied to the higher-valued procedure, based on 100 percent of the eligible charge. Other codes within the same family are paid based on their eligible charge, minus the fee for the family's base procedure (since an allowance for the base procedure is included in the eligible charge for the higher-valued procedure).

   Example:
   A gastroenterologist performed two procedures in the colonoscopy family. The procedures are:

   CPT Code	Description
   45380	Colonoscopy, flexible; with biopsy, single or multiple
   45385	Colonoscopy, flexible; with removal of tumor(s), polyp(s) or other lesion(s) by snare technique

   The base code for these procedures is:

   CPT Code	Description
   45378	Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

   When the gastroenterologist's claim for 45380 and 45385 is processed, it will be paid as follows:

   • 45385 is the highest-valued procedure, with a 2015 eligible charge of $544.17. Plan benefits for this procedure will be paid based on 100 percent of the eligible charge.
   • 45380 has a 2015 eligible charge of $458.84, and the base procedure, 45378, has a 2015 eligible charge of $387.76. To determine the eligible charge for 45380, subtract $387.76 from $458.84, which results in a difference of $71.08.

   The eligible charges for these two procedures are as follows:

   45385	$544.17
   45380	$71.08
   Total	$615.25

   If the member's plan benefit for endoscopy is 90 percent of the eligible charge, HMSA would pay $553.73 and the member would have a copayment of $61.52.

2. Unrelated Endoscopic Procedures
   When two unrelated endoscopies (e.g., lower and upper GI) are performed on the same day, the multiple endoscopy rules are not applied, because the endoscopies are not in the same family. However, these procedures are subject to HMSA's multiple surgery rules. Under the multiple surgery rules, plan benefits for the procedure with the higher-valued code are applied based on 100 percent of the eligible charge. Plan benefits for the second procedure are applied based on 50 percent of the eligible charge for the procedure. (Refer to Multiple Surgical Procedures)

3. Multiple Endoscopies, more than one family
   HMSA recognizes the endoscopy families as published by the Centers for Medicare & Medicaid Services (CMS) in the National Physician Fee Schedule – Relative Value Files.

   Note: January 1, 2015 through December 31, 2015, there were 21 new lower gastrointestinal codes which were listed in the National Physician Fee Schedule – Relative Value File as being applicable to multiple endoscopy rules but a Base Code was not listed. Therefore, HMSA derived the following base codes for the CPT codes listed below.

   CPT Code	Base Code
   44381, 44384	44380
   44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408	44388
   45346, 45347, 45349, 45350	45330
   45388, 45389, 45390, 45393, 45398	45378
   46601, 46607	46600

Revision History