Forum - Questions & Answers

Mar 16th, 2022 - Endocenter 4 

Ercp codes

Hi.  Can anyone tell me if you can bill CPT codes 43265 and 43274 togther?

Mar 21st, 2022 - ChrisW   256  1 


Without additional information on the procedure, here are a few things to consider, multiple CPT codes may be reported if applicable, there are no CCI edits on these, however, if both codes were done during the same procedure, you would only get paid 100% for the initial procedure since they are both endoscopic procedures.
You should be able to bill both procedures if you modify the second procedure, you want to bill the most expensive CPT first or the code with the highest RVU's as you will get paid 100% on the primary procedure and 50% on the additional procedure.
Consider the use of modifier 51, indicating multiple procedures were performed at the same patient encounter. To understand when to use modifier 51 or Modifier 50 with a code refer to the Medicare Fee schedule indicator. For example, CPT 43274, has indicator # 3.  The Medicare rules applicable to indicator #3 are below. Keep in mind Medicare is not the only payer that uses these rules, if you have further questions, I would advise contacting your payer. 
“Multiple Procedures (51): 3
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.”
NOTE: In addition, if a single-use endoscope was used you may want to consider reporting; C1748 Endoscope, single-use (i.e., disposable), upper GI, imaging/illumination device (insertable).

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