Monday, June 21, 2010

Multiple endoscopy performed on the same day - Billing update from BCBS

 BCBS Florida applying new rule for multiple endoscopy performed on the same day.


Effective September 1, 2010, Blue Cross and Blue Shield of Florida, Inc. (BCB Inc. will begin applying new payment rules for certain multiple endoscopy procedure performed for the same patient, on the same day, during the same session. These new payment rules attempt to more appropriately and precisely value the secondary procedures based upon the additional resources required to perform them. The Centers for Medicare & Medicaid Services (CMS) has applied similar procedure logic for several years.

BCBSF has identified 31 endoscopic groups which will be subject to these new payment rules. Each grouping of related endoscopic procedures shares the same “base code.” A base code is a procedure whose allowance is included in the allowance for the other related endoscopic procedure codes within that particular grouping. As of September 1, 2010, for endoscopy procedures identified within the same  grouping, BCBSF will determine the allowance for the secondary procedures as the allowance of the secondary procedures and the allowance for base code. The primary procedure (which will be the highest valued procedure based upon the CMS relative value units) will continue to be paid at 100 percent of the contracted allowed amount less the applicable member responsibility amount. The following example is offered for further explanation:

In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. BCSBF 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). BCBSF will pay the full value of 45385, plus the difference between 45380 and 45378.

If an endoscopic procedure is billed with other procedures that are not endoscopies, the standard multiple surgery rules apply. Additionally if endoscopies are performed on the same day as unrelated endoscopies or other surgical procedures BCBSF will continue to apply the standard multiple surgery rules.

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