Endoscopic Pricing Method
The endoscopic pricing method is denoted by an indicator of (3) under the “Mult Proc” column on the MPFSDB.
Calculate the allowance and limiting charge (non-assigned claims only) at:
One hundred percent for the procedure with the highest fee schedule amount.
Subsequent procedures equal subsequent procedure allowance minus basic endoscopic allowance.
The pricing formula for multiple endoscopic procedures varies depending on which procedures are billed.
Same Endoscopic Family
When two or more endoscopies are billed that are both in the same endoscopic family, Medicare prices the highest allowed procedure at 100 percent of the fee amount. The other procedures are priced by subtracting the fee amount of the basic endoscopy from their fee amounts.
Example: The following example demonstrates endoscopic pricing in the same endoscopic family.
Codes Definition Indicator Fee Amount $ Allowance $
45305© Proctosigmoidoscopy w/bx 3 130.39 – 68.08 = 62.31 x 80%
45307© Proctosigmoidoscopy fb 3 138.62 138.62 x 80%
Base Endoscopy
45300© Proctosigmoidoscopy dx 2 68.08
Different Endoscopic Family
When two or more endoscopies that are both in the same endoscopic family are billed along with another procedure that is either non-endoscopic or endoscopic from a different family, price the two endoscopies that are in the same family as indicated in Example 1. The allowance of the two procedures should be added together and then compared to the third procedure.
Example: The following example demonstrates endoscopic pricing from different endoscopic families.
Codes Definition Indicator Fee Amount $ Allowance $
*45305© Proctosigmoidoscopy w/bx 3 130.39 – 68.08 = 62.31 31.16 x 80%
62.31 x 50% = 31.16
*45307© Proctosigmoidoscopy fb 3 138.62 138.62 x 50% = 69.31 69.31 x 80%
52325© Cystoscopy, stone removal 3 304.06 @ full physician allowance 304.06 x 80%
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1 comment:
so if the second procedure was a different family does it get the 51 modifier and paid at 50%???
example:
45305 proctosigmoidoscopy w/bx
45307 proctosigmoidoscopy
43200 Esophagoscopy - 51
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