Background
When multiple surgical procedures are performed on the same date, special pricing methodology is used to determine Medicare reimbursement. In most cases, multiple endoscopic procedures are reimbursed differently from other concurrent (non-endoscopic) surgical procedures.

• Surgical procedures are identified in the Medicare Physician Fee Schedule Database (MPFSDB) by certain 'multiple surgery indicators'. To access the MPFSDB, access the CMS Web site at www.cms.hhs.gov/PFSlookup/
  • Under Type of Information, select Payment Policy Indicators
  • Select 'Next'
  • Enter the procedure code and select 'All Modifiers'
  • Refer to the column heading 'Mult Surg'
• It is not necessary to submit multiple surgical procedures with CPT modifier 51. Palmetto GBA will add this modifier when processing claims according to multiple surgery pricing guidelines.

Endoscopies in the Same Family
Endoscopies in the same 'family' (i.e., those that share the same base procedure) are reimbursed according to special rules:

• Endoscopic procedures are identified in the Medicare Physician Fee Schedule Database with multiple surgery indicator '3'
• The endoscopic procedure with the highest fee schedule amount is reimbursed at the highest level. If no other surgical procedures, other than same family endoscopies, are performed on the same date, reimbursement for this procedure is based on the actual fee schedule amount, unless the submitted amount is less than the fee schedule amount.
• Reimbursement for the base procedure is determined. Base procedures are easily identified from the CPT manual; these procedures are left-justified, and other codes in the endoscopic family are indented under each base procedure.
• The reimbursement amount for the base procedure is subtracted from all endoscopic procedure(s) performed on that date except for the procedure with the highest fee schedule amount
• If the endoscopy and its base procedure are the only endoscopies submitted, the base endoscopy will not be reimbursed separately (it is included in the other procedure)

• CPT codes 45382 and 45385 have a multiple surgery indicator of '3'. The base endoscopy code for both procedures is CPT code 45378.

Date of Service	CPT Code	Submitted Amount	Fee Schedule Amount (participating, in WV)	Reimbursement Basis
1/16/2007	45382	$350.00	$290.96	Because CPT code 45382 has the highest fee schedule amount, the full fee schedule amount is used to determine reimbursement (subject to coinsurance & deductible)
	45385	$325.00	$272.74	Base procedure: CPT code 45378 (fee schedule amount = $191.91) $272.74 - $191.91 = $80.83 (subject to coinsurance & deductible)

Two Endoscopies, Each in Different Families
Endoscopies that are not in the same 'family' are reimbursed according to regular multiple surgery pricing methodology.

• 'Standard payment adjustment rules' are used to calculate reimbursement for endoscopic procedures in different families
• If the endoscopic procedure is reported on the same date as another procedure with a 'multiple procedure indicator' of 2 or 3, the procedures are first ranked by fee schedule amount from highest to lowest
• The procedure with the highest fee schedule amount is reimbursed at the highest level
• Reimbursement for all procedures, except for the procedure with the highest fee schedule amount, is based on 50 percent of the fee schedule amount

Example
Office setting: endoscopies in different families:

• CPT code 45385 has a multiple surgery indicator of '3'. Its base endoscopy code is CPT code 45378.
• CPT code 43235 has a multiple surgery indicator of '2'. It is the base code for a different endoscopy family.

Date of Service	CPT Code	Submitted Amount	Fee Schedule Amount (participating, in OH)	Reimbursement Basis
1/24/07	45385	$525.00	$477.10	Because CPT code 45385 has the highest fee schedule amount, the full fee schedule amount is used to determine reimbursement (subject to coinsurance & deductible)
	43235	$350.00	$272.10	Medicare allows 50% of the fee schedule amount, which is $136.05 (subject to coinsurance & deductible)

Multiple Endoscopies in Same Family Performed with Other Surgical Procedures
Endoscopies that are performed on the same date as other surgical procedures are subject to both special endoscopic pricing and regular multiple surgery pricing methodology.

• First, pricing is determined for all codes in the endoscopic family according to the endoscopic pricing rules
• Next, the family of endoscopic codes is considered against the other surgical procedures
• The 'family' of endoscopic codes is considered as a single procedure (fee schedule amounts are combined)
• The 'family' and the other surgical procedures are ranked by fee schedule amount from highest to lowest
• Reimbursement for all procedures (except for the procedure with the highest fee schedule amount) is based on 50 percent of the fee schedule amount

Example
Inpatient hospital setting, multiple endoscopies performed with other surgical procedures:

• CPT code 45562 has a multiple surgery indicator of '2'. It is not an endoscopy.
• CPT codes 45380 and 45381 have a multiple surgery indicator of '3'. The base endoscopy code for both procedures is CPT code 45378.

Date of Service	CPT Code	Submitted Amount	Fee Schedule Amount (participating, in OH)	Reimbursement Basis
1/19/2007	45562	$1000.00	$932.12	Because CPT code 45562 has the highest fee schedule amount (see step 4), the full fee schedule amount is used to determine reimbursement (subject to coinsurance and deductible)
	45380 45381	$300.00 $275.00	$229.76 $217.15	Step 1: CPT code 45380: full fee schedule amount ($229.76) Step 2: Base procedure: CPT code 45378 (fee schedule amount = $192.31) CPT code 45381: fee schedule amount minus base scope ($217.15 - $192.31) = $24.84 Step 3: Add adjusted amounts for CPT codes 45380 and 45381: $229.76 + $24.84 = $254.60  Step 4: Since the combined amount for the endoscopic procedures is less than the fee schedule amount for CPT code 45562, reduce the following codes: CPT code 45380: $229.76 x 50% = $114.88 (subject to coinsurance & deductible)  CPT code 45381: $24.84 x 50% = $12.42 (subject to coinsurance & deductible)

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