Awareness : Newsletter Articles

Endoscopic Procedures: Be Aware of the Summary of “Family Codes”

Special rules for multiple endoscopic procedures apply if a 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 Endobase field of this file.
  • 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 billed 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.
  • CPT® classifies endoscopic procedure codes by “family,” where each family is comprised of related services. Each family has a “parent” code—called the endoscopic base code—that represents the most basic version of that endoscopic service.
  • Usually, the base code is the first-listed code within a sequence of codes in CPT®. For example, consider this partial code family:
    • 45300 Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)    
    • 45303 …with dilation (e.g., balloon, guide wire, bougie)    
    • 45305 …with biopsy, single or multiple    
    • 45307 …with removal of foreign body
  • In this case, 45300 describes the most basic version of the service. Codes 45303, 45305, 45307, etc., include the work of 45300, plus additional work defined by the code descriptor.

  • The endoscopic base code within each family is in the Medicare Physician Fee Schedule Relative Value File. The Relative Value File is updated at least annually (and often several times per year), and can be downloaded from the CMS website.

  • The column labeled “ENDO BASE” will tell you the parent code for every endoscopic procedure. If there is no code in “ENDO BASE” column, the code in column “A” is the base code (or the code in column “A” is not an endoscopic procedure). You can confirm the multiple-scope rule applies to a given code if you find a “3” in the “MULT PROC” column.

NOTE: If you’re not coding for a hospital outpatient facility but rather the physician’s professional service, CPT says to use modifier 52 (Reduced services) to report an incomplete colonoscopy; CMS says to use modifier 53 (Discontinued procedure) to report a colonoscopy if the physician was unable to view farther into the colon than the splenic flexure. Which you’ll use depends on your insurer.

CMS Focuses on the Splenic Flexure.

  • CMS is fixated on the splenic flexure, the bend that separates the transverse colon from the descending colon. Medicare pays at the rate of a lesser procedure if the colonoscopy doesn’t make it past this bend.

From the Medicare Claims Processing Manual: “Failure to extend beyond the splenic flexure means that a sigmoidoscopy rather than a colonoscopy has been performed.” A sigmoidoscopy is an inspection of the descending colon only.

  • CMS does advise using code 45378-53 if a colonoscopy was intended “because other Medicare physician fee schedule database indicators are different for codes 45378 and 45330”.

    The entire rule is available online at Medicare Claims Processing Manual