NC Medicaid has updated endoscopy codes, aligning base codes with related procedures in the same family as well as creating one new endoscopy family. These updates are effective in NCTracks on July 31, 2022. The newly created endoscopy family is below:
|
Base Code |
Related Codes |
|
31231 |
31233, 31235, 31237, 31238, 31239, 31240, 31241, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31290, 31291, 31292, 31293, 31294, 31295, 31296, 31297, 31298, 69705, 69706 |
Endoscopy Pricing
A value of ‘3’ in the Multiple Procedure field on the 2022 National Physician Fee Schedule Relative Value File January Release indicates special rules for multiple endoscopic procedures apply if the 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.
Multiple endoscopy pricing rules will be applied to a group before it is ranked with other procedures performed on the same day (i.e., when multiple endoscopies in the same group reported are reported on the same day as endoscopies from another group, or on the same day as a non-endoscopic procedure).
If an endoscopic procedure and its base procedure code are billed on the same claim, no separate payment will be made for the base code. Payment for the base code is included in the payment for the other endoscopy.
If an endoscopic procedure is billed with a 51 modifier with other procedures that are not endoscopies (i.e., surgical procedures), the standard multiple surgery guidelines apply.
Examples of Medicaid Pricing
Multiple endoscopies in the same group
- The system determines the highest-paying procedure and allows payment at 100 percent.
- For the other endoscopies, the system subtracts the allowance for the group’s base code from the allowance for the related endoscopy and allows the difference.
Multiple endoscopic procedures in different groups
For the first group
- The system determines the allowance for the highest paying procedure and pays at 100 percent.
- The system determines the allowance for the other related endoscopic procedures by subtracting the allowance for the group’s base code from the allowance for the related endoscopy and pays the difference.
For other groups
- The system follows the same method of determining the allowance for each procedure reported within a group.
- The system compares the total allowance for each group; pays the highest paying group at 100 percent and the remaining groups at 50 percent.
Multiple endoscopies in one group reported with one endoscopy from a different group
For the first group
- The system determines the allowance for the highest paying procedure and pays at 100 percent.
- The system determines the allowance for the other related endoscopic procedures by subtracting the allowance for the group’s base code from the allowance for the related endoscopy and pays the difference.
For the endoscopy in a different group
- The system considers that code to be a separate group and obtains the allowance for this code.
- The system determines the total allowance for each group and pays the group with the highest allowance at 100 percent and the remaining group at 50 percent.
One endoscopy in one group reported with one endoscopy from a different group
- The system pays the highest paying procedure at 100 percent of the allowance.
- The system pays the other endoscopy at 50 percent of its allowance.
Multiple endoscopies in one group and one is that group’s base code reported with multiple endoscopies in a different group
For the group that includes the base code
- The system determines the allowance for the highest paying procedure and pays at 100 percent.
- The system denies the base code because the allowance for the base code is included in the allowance for the highest paying procedure.
For the endoscopies in the other group(s)
- The system determines the highest paying procedure and pays at 50 percent.
- For the remaining endoscopies in that group, the system subtracts the allowance for the
Contact
NCTracks Call Center, 800-688-6696