Medicare uses different rules to pay for multiple surgical procedures and multiple endoscopic procedures. For non-endoscopic procedures, the service with the highest RVU is paid at 100% of the fee schedule, and at 50% for the second to the fifth procedure.
Multiple unrelated endoscopic procedures are paid using the same formula as multiple surgical procedures.
Multiple relatedendoscopic procedures are paid in this way:
100% of the fee schedule for the service with the highest RVU
Second and subsequent procedures are paid the difference between the RVU for that procedure and the RVU for the base procedure in that family of codes.
This is how the Medicare Claims Processing Manual describes the process in its instructions to carriers:
13. If Field 21 contains an indicator of “3,” and multiple endoscopies are billed, the
special rules for multiple endoscopic procedures apply. Pay the full value of the
highest valued endoscopy, plus the difference between the next highest and the
base endoscopy. Access Field 31A of the MFSDB to determine the base
endoscopy.
###
Questions, comments?
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
On January 5, 2021, H.R. 7898 was signed into law by President Trump. This new law modifies the HITECH Act such that when an organization experiences a breach, fines and/or penalties may be reduced if (for at least a year) they have instituted “recognized security practices” as defined within the law.
Reporting a CPT code for an evaluation of a patient is based on time and if the patient is a new or established patient. Evaluation and Management codes are different than other codes, it is important to understand how they are used, prior to 2021 they were based on a ...
On November 10, 2020, the American Medical Association (AMA) announced the addition of two new codes which will be used for the new COVID-19 vaccines along with 4 new administration codes to be used when reporting the administration of these vaccines.
Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues:
Quality of ...
It is no secret that Medicare and Medicaid are steadily moving towards their goal of value-based health care. Medicare Part C (Medicare Advantage) identifies and rewards payers, and subsequently their providers, for increasing the efficiency and quality of care they provide to Medicare...
