Thursday, November 3, 2016

Payment Rules for Multiple Scope Procedures


Related Scope Procedures: Scope surgeries are related procedures (same code family) performed during the same operative session and through the same body orifice/incision on the same day.

The scope with the highest RVU is allowed at 100 percent of the fee allowance.

The second and subsequent procedures are priced by subtracting the fee allowance for the “base” procedure from the code’s usual fee allowance.

Unrelated Scope Procedures: When the Scope Procedures are unrelated (not in the same family), multiple surgery rules will apply instead.

Related and Unrelated Scope Procedures on the same day: First, the related scope procedure rule applies, and if the scope is determined to be unrelated then the multiple surgery rule will apply.

Examples of Scope Procedure Families:

45378 Base procedure 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387, 45391, 45392


Examples of Laparoscopy Families:

49320 Base procedure 38570, 49321, 49322, 49323, 58550, 58660, 58661, 58662, 58663, 58670, 58671, 58672, 58673


Example 1: The procedures performed are 45378 (B), 45385, and 45380 and are based on 2009 Fully Implemented Facility RVUs.

Procedure     Description         RVUs          Allowed RVUs           RVU Minus Base          Total RVU

45378 (B) Colonoscopy 5.87 5.87

45385 With direct submucosal injection(s), any substance  8.41 2.54 (8.41-5.87)

45380 With biopsy, single or multiple 7.09 1.22 (7.09-5.87) 9.63


Example 2: The procedures performed are 45380 and 45385 (base code not billed) and are based on 2009 Fully Implemented Facility RVUs.

Procedure       Description           RVUs           Allowed RVUs        RVU Minus Base           Total RVU

45378 (B) Colonoscopy 5.87

45385 9.36 With direct submucosal injection(s), any substance 8.41 8.41

45380 With biopsy, single or multiple 7.09 1.22 (7.09-5.87)

Example 3: The procedures performed are 49320(B), 58660, and 58661, and are based on the 2009 Fully Implemented Facility RVUs.

Procedure            Description          RVUs          Allowed RVUs              RVU Minus Base        Total RVU

49320 (B) Laparoscopy 8.25 8.25

58660 Laparoscopy, surgical; with 26.20 lysis of adhesions 17.62 9.37 (17.62-8.25)

58661 16.83 8.58 (16.83-8.25)


Example 4: The procedures performed are 58660 and 58661 (base code not billed) and are based on 2009 Fully Implemented Facility RVUs.

Procedure         Description           RVUs        Allowed RVUs       RVU Minus Base           Total RVU

49320 (B) Laparoscopy 8.25

58660 Laparoscopy, surgical; with 26.20 lysis of adhesions 17.62 17.62

58661 16.83 8.58 (16.83-8.25)

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