Get your Scopes Right for Orthopedic Billing!

An orthopedic surgeon performing a knee arthroscopy does several procedures. You will certainly need to understand the multiple-scope rule to determine the procedures that you can claim and get paid for.

The multiple-scope rule mainly applies to shoulder and knee procedures in the orthopedic practice. However, it also affects the elbow, wrist, and hip procedures. On the other hand, it does not apply to ankle or metacarpophalangeal (MCP) arthroscopy; and arthroscopically aided procedures (29851, 29855-29856, 29888-29889, and 29892). In addition, some other surgical knee arthroscopies excluded from the family are 29866-29868, specifically.

What you need to know about CPT® Codes?

Below are some expert-approved tips to clinch your coding every time.

  1. Look to CPT® for Scope ‘Families’

The rule of multiple-endoscopy is Medicare’s method to prevent you from paying twice (or more) for inclusive services by reimbursing a portion of any scope that has been performed at the same time as another scope of the same basic type.

But how does this work? CPT® divides groups of similar codes into families. The first code, which is the base or parent code, describes the basic procedure. After the base code, CPT® lists the variants, if any, that are more extensive than the base code. This rule applies only if a surgeon performs two or more endoscopies that are members of the same code family.

2. Include the ‘Base’ Procedure

Family codes include the work involved in the base code, whereas, a surgical scope always includes the diagnostic scope of the same type. However, you should only report the more extensive procedure.

3. No Base Procedure? Bill Both Scopes

In case, the surgeon has performed two scopes in the same family, and neither of them is the base procedure, it will be the safest for you to report both codes. Do remember to watch out for CCI bundles as the National Correct Coding Initiative (NCCI) will impose additional bundles on arthroscopic procedures falling outside the multiple-scope rule. Therefore, before submitting a multiple-arthroscopy claim, your best bet would be check it against CCI edits to ensure that you have not over-coded.

4. Watch Your Reimbursement

Medicare, under the multiple-scope rule, will pay you the entire fee schedule amount only for the scope with the highest-value in a given code family during the same operative session. However, any additional scope in the same family will be reimbursed, as the Medicare carriers will subtract the value of the base scope in that family and pay the difference to you.

For insights on the changes that will affect Orthopedic Offices for the FY 2017, attend this Webinar by expert speaker Margie Scalley Vaught, CPC, CPC-H, CPC-I, CCS-P, PCE, MCS-P, ACS-EM, ACS-OR, who has over 30+ years’ experience in the healthcare industry, and understands how offices are structured. You will also learn about the new/revised/deleted CPT® codes for orthopedic offices for FY 2017.


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