Endoscopy Procedures and

Calculations
Presented by Noridian Part B Medicare
Provider Outreach and Education
December 2015
 DISCLAIMER
This information release is the property of Noridian Healthcare Solutions, LLC. It may be
freely distributed in its entirety but may not be modified, sold for profit or used in
commercial documents.
The information is provided as is without any expressed or implied warranty. While all
information in this document is believed to be correct at the time of writing, this
document is for educational purposes only and does not purport to provide legal advice.
All models, methodologies and guidelines are undergoing continuous improvement and
modification by Noridian and CMS. The most current edition of the information
contained in this release can be found on the Noridian website at
http://www.noridianmedicare.com and the CMS website at http://www.cms.gov
The identification of an organization or product in this information does not imply any
form of endorsement.
CPT codes, descriptors, and other data only are copyright 2015 American Medical
Association. All rights reserved. Applicable FARS/DFARS apply.

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 Objectives
To increase your knowledge of Medicare
coverage and billing guidelines
To give you a better understanding of
billing endoscopy procedures
To understand how Medicare pays for
endoscopy procedures
To help protect the Medicare Trust Fund

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 Agenda
Basic information on Endoscopy
Procedures
Medicare Physician Fee Schedule Data
Base

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 Helpful Acronyms
Acronym Description
CWF Common Working File
IOM Internet Only Manual
MPFSDB Medicare Physician Fee Schedule Data Base
NCCI National Correct Coding Initiative
PTP Procedure to Procedure Edit

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Endoscopic Procedures

December 2015
 Endoscopy Procedures
Medicare Physician Fee Schedule Data
Base
Multiple Surgery
Indicator 3
Special rules apply
Multiple Related Procedures
Multiple Unrelated Procedures
Related and Unrelated Procedures

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 Accessing MPFSDB Information
www.noridianmedicare.com/jeb
Fee Schedules

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www.noridianmedicare.com/jeb

December 2015 9
Fees and News

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MPFS

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Medicare Fee Schedule

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2015 MPFS Indicator Description

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 Understanding
Indicators/Descriptors

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Indicators/Descriptors

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 Endoscopic Procedures
Multiple Related Procedures
Highest value endoscopic procedure allowed
at 100%
Subsequent related endoscopies reimbursed
on difference between base code and
subsequent code

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 Endoscopic Related Procedure
Procedure Code Allowed Amount Approved Amount

45385 $374.56 100% of PFS

45380 $285.98 Difference

between 45380
45378 (base and base code
code) (45378) $285.98
255.40
$ 30.58

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 Endoscopic Procedures
Multiple Set of Unrelated Endoscopies
Highest valued endoscopic procedure allowed
at 100%
Subsequent unrelated endoscopy is allowed
at 50%

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 Endoscopic Unrelated Procedure
Procedure Code Allowed Amt Approved Amount

29827 $1,135.33 100% of PFS

29834 $ 523.55 Multiple surgery
rule apply

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Two Sets of Unrelated Procedures
Apply the special endoscopy rules to each
series
Then apply multiple surgery rules
Consider the total payment for each set of
endoscopies as one service

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Endoscopic Unrelated Sets Procedure
Procedure Code Allowed Amt Approved Amount

43217 $509.76 100% of PFS

43202 $418.18 Difference
(43200 base between 43202
code) and base code
(43200) $418.18
310.22
107.96
43217 + 43202 $509.76 + $617.72
$107.96

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 Endoscopic Unrelated Sets
Procedure2
Procedure Code Allowed Amt Approved Amount

46608 $270.03 100% of PFS

46606 $257.91 Difference
(46600 base between 46606
code) and base code
(46600) $257.91
100.71
$157.20
46608 + 46606 $270.03 + $427.23
$157.20

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 Endoscopic Unrelated Sets
Procedure3
Procedure Code Allowed Amt Approved Amount

43217/43202 $617.72 100% of PFS

46608/46606 $427.23 50%

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Endoscopy Related and Unrelated
Related and Unrelated Endoscopies on
same day
Organize the related endoscopies into a
group
Organize the unrelated endoscopies into a
group
Determine highest allowable amount in each
group
Multiple surgery rule apply

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 Endoscopic Related Procedure1
Procedure Code Allowed Amount Approved Amount

45385 $374.56 100% of PFS

45380 $285.98 Difference

between 45380
45378 (base and base code
code) (45378) $285.98
255.40
$ 30.58
45385 + 45380 $374.56 + $30.58 $405.14

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 Endoscopy Unrelated Procedure2
Procedure Code Allowed Amount Approved Amount

29835 $540.03 100% of PFS

29834 $523.55 Difference
between 29834
and base code
(29830) $523.55
485.15
$ 38.40
29835 + 29834 $540.03 + $38.40 $578.43

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Endoscopic Unrelated Procedure3
Procedure Code Allowed Amount Approved Amount

45385 & 45380 405.14 50% of

calculated
amount $202.57
29835 & 29834 $578.43 100% of
calculated
amount

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 Endoscopy Unrelated Procedure3
Procedure Code Allowed Amount Approved Amount

29835 $540.03 100% of PFS

29843 $522.12 50% of PFS

29835 + 29843 $540.03 + $801.09

$261.06

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 Endoscopic Unrelated Procedure
Procedure Code Allowed Amount Approved Amount

45385 & 45380 405.14 50% of

calculated
amount $202.57
29835 & 29843 $801.09 100% of
calculated
amount

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NOTEWORTHY
INFORMATION

December 2015
 Upcoming Part B Webinars
Date Time (CT) Webinar Title
12/8/15 1:00 PM Transitional Care Management
Local and National Coverage
12/9/15 1:00 PM
Determination
12/10/15 1:00 PM Incentive Program
12/15/15 3:00 PM Quarterly Provider Update
Incident to, Non Physician Practitioner,
12/16/15 1:00 PM
Locum Tenens and Reciprocal Billing
Chronic Care Management (CCM)
12/17/15 1:00 PM
Requirement
REGISTER NOW!
JE https://med.noridianmedicare.com/web/jeb/education/training-events
JF https://www.noridianmedicare.com/partb/train/workshops/index.html
December 2015 31
 CEU Process Reminder
When registering, add additional attendees
First and last names
Attend entire workshop
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December 2015 32
 Questions?

Thank you!