Quick Q&A to Take Multiple Scope Know-How Up a Notch

multiple scope rule

Happy New Year! We’ve made it to the last SuperCoder blog post for 2016, and what a year it’s been. Sometimes after a whirlwind of chaos, it’s good to get back to the fundamentals. With that in mind, today we’re looking at some simple tips for the next time you’re dealing with the multiple scope rule, a crucial concept if you want to understand the Medicare Physician Fee Schedule (MPFS).

1. Where Can I See Some Sample Calculations?

The basic idea behind the multiple scope rule is that if the surgeon performs multiple endoscopic procedures on a patient at the same session, then you’ll receive full reimbursement for the highest valued procedure and reduced reimbursement for the others.

For subsequent related endoscopies, you get paid based on the difference between the base code (defined in question 2) and subsequent code.

If the subsequent endoscopy is in a different family, expect that subsequent scope to get paid at a discounted rate under multiple surgery rules.

For two sets of unrelated procedures, things get really interesting. You apply the special endoscopy rules to each series, then apply multiple surgery rules.

Helpful: For sample calculations, click the link to see a Multiple Endoscopic Procedures document from Palmetto.

And feel free to share that info with any math teachers you know who have students claiming they’ll never use math when they’re adults.

2. Where Can I Find the Base Code for an Endoscopic Procedure?

Within the code ranges for endoscopic procedures are code families, meaning those that have descriptors that share a common beginning but then differ after the semicolon. Typically you can find the base procedure code by looking for the first code in a family of codes.

Example: Code 43191 is the base code for 43192-43196. All of their descriptors begin with “Esophagoscopy, rigid, transoral,” but then a semicolon and additional text follows that initial wording, distinguishing each code from the rest. For instance, look at how 43191 and 43192 differ in descriptor wording only after the semicolon:

  • 43191, Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or washing when performed (separate procedure)
  • 43192, Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance.

To confirm that you have the correct base code, you can check the ENDOBASE (Endoscopic Base Codes) column of the MPFS database. Your online coding resource may provide the information, or you can go to Medicare’s Physician Fee Schedule Search tool.

For instance, if you check the ENDOBASE (Endoscopic Base Codes) entry for 43192, you’ll see 43191 listed.

Knowing the base code helps in calculating reimbursement, as question 1 mentioned, but it’s also important to know that the base endoscopy won’t be reimbursed separately when reported with another code from the same family.

3. Where Can I Find the Multiple Procedure Indicator?

The MPFS includes a MULT SURG (aka Multiple Procedure or Modifier 51) column. In the Multiple Procedure column, you want to look for two indicators in particular, 2 and 3, to see how the multiple scope rule will affect your reimbursement. Here are the definitions from the Medicare Claims Processing Manual (page 95 of the linked PDF):

  • 2 = Standard payment adjustment rules for multiple procedures apply. If the procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by report). Base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.
  • 3 = Special rules for multiple endoscopic procedures apply if 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 endoscopic base code field. 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.

You may see indicator 2 with a base procedure code and indicator 3 with other codes in the code family.

Final tip: Although you may see the MULT SURG column referred to as the modifier 51 column, Medicare and some other payers ask that you not use modifier 51 (Multiple procedures). The payer will take care of that for you.

How About You?

What questions do you have about the multiple scope rule?



Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

, , , ,

Leave a Reply