Forum - Questions & Answers
43264 and 43275
Can anyone tell me if these 2 codes can be billed together?
re: 43264 and 43275
Yes, these codes can be billed together; however, there are payment rules that apply when doing more than one endoscopic procedure. It is important to point out that the payment for the base procedure is included in the payment for the other endoscopy.
Modifier 51 usage
When doing two endoscopic procedures, you would report multiple procedures with modifier 51. When reporting Modifier 51, the Medicare physician fee schedule indicator tells us these codes have both been assigned an indicator #3 – “Special payment adjustment rules for multiple endoscopic procedures apply.”
Rules for payment adjustment
Special rules for multiple endoscopic procedures apply if the procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in the Endobase field of this file. Apply the multiple endoscopy rules to a family before ranking the family with the other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure. Payment for the base procedure is included in the payment for the other endoscopy.
Find-A-Code is an excellent source of information to help you understand code assignments with indicators. The NCCI editor tool in Find-A-Code will verify which codes can be billed together, and if they are not billable, the rationale is provided in the NCCI edits manual.