Medicare endoscopic payment pricing method - Multiple procedure

Endoscopic Pricing Method

The endoscopic pricing method is denoted by an indicator of (3) under the “Mult Proc” column on the MPFSDB.

Calculate the allowance and limiting charge (non-assigned claims only) at:

One hundred percent for the procedure with the highest fee schedule amount.

Subsequent procedures equal subsequent procedure allowance minus basic endoscopic allowance.
The pricing formula for multiple endoscopic procedures varies depending on which procedures are billed.

Same Endoscopic Family

When two or more endoscopies are billed that are both in the same endoscopic family, Medicare prices the highest allowed procedure at 100 percent of the fee amount. The other procedures are priced by subtracting the fee amount of the basic endoscopy from their fee amounts.

Example: The following example demonstrates endoscopic pricing in the same endoscopic family.


Codes                Definition           Indicator Fee Amount $      Allowance $ 
45305©  Proctosigmoidoscopy w/bx 3 130.39 – 68.08 =       62.31 x 80%
45307© Proctosigmoidoscopy fb      3  138.62                      138.62 x 80%

Base Endoscopy

45300© Proctosigmoidoscopy dx 2   68.08

Different Endoscopic Family
When two or more endoscopies that are both in the same endoscopic family are billed along with another procedure that is either non-endoscopic or endoscopic from a different family, price the two endoscopies that are in the same family as indicated in Example 1. The allowance of the two procedures should be added together and then compared to the third procedure.

Example: The following example demonstrates endoscopic pricing from different endoscopic families.

Codes     Definition                     Indicator             Fee Amount $                        Allowance $
*45305© Proctosigmoidoscopy w/bx 3                 130.39 – 68.08 =  62.31        31.16  x 80%
                                                                            62.31 x 50% = 31.16
*45307© Proctosigmoidoscopy fb   3                138.62   138.62 x 50% = 69.31   69.31  x 80%

52325© Cystoscopy, stone removal 3        304.06 @ full physician allowance     304.06 x 80%