Forum - Questions & Answers
Colonoscopies
Can you code 45380 with 45385. Can you code biopsy colonoscopies with polypectomies?
Endoscopy, multiple procedures
If a physician performs a biopsy on one lesion (45380) and also removes a polyp, through the scope (45385), Medicare pays based on "Special Endoscopy" rule. The value of codes 45380 and 45385 both have the value of the diagnostic colonoscopy (45378) built in (not separately billed). Rather than paying 100 percent for the highest valued procedure (45385) and 50 percent for the next (45380), Medicare will pay the full value of the higher valued endoscopy (45385) plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).
Assume the following are the fee schedule allowables for these codes (check your fee schedule for your actual amounts):
45378 - $266.48
45380 - $291.97
45385 - $387.90
Medicare will approve payment for the full value of 45385 ($387.90) plus the difference between 45380 and 45378 ($25.49) for a total of $413.39.
Endoscopy, multiple procedures
I have added Nancy's answer to the article in Codapedia about colonoscopy. The article is entitled "Colonoscopy" (alright, it has a basic title!) and can be found by searching in the box above "look it up."
There's also an article on multiple endoscopic procedures, and one on incomplete colonoscopies.
Special Endoscopy Rule
I have tried every resource that I can find without success to validate a source within CMS regarding the "Special Endoscopy" rule. Can you cite the CMS source for this special payment rule? Is it specific to one Medicare Administrative Contractor? Thank you.
Multiple Endoscopy Payment Rules
There is a nice article publichsed by Palmetto GBA at this link about the multiple endoscopy payment method: http://www.palmettogba.com/Palmetto/Providers.nsf/DocsCat/Ohio%20Part%20B%20Carrier~Browse%20by%20Specialty~Surgery~B3B53521A0C581908525761D005B4E09
The article references the information from CMS on the Physician Fee Schedule page.
multiple endoscopy rules
Thanks: I've added that citation as citation to the article on colonoscopies.