Description
Surgical endoscopy includes diagnostic endoscopy. A diagnostic endoscopy HCPCS/CPT code shall not be reported with a surgical endoscopy code. If multiple endoscopic services are performed, the most comprehensive code describing the service(s) rendered shall be reported.
Affected Code(s)
45378, 45330
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §50.6- Physician Fee Schedule Payment Policy Indicator File Record Layout
9. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum - MPFSDB Record Layouts 20 - Professional Component (PC)/Technical Component (TC) Indicator
10. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum - MPFSDB Record Layout and Field Descriptions; MPFSDB File Record Layout for 2018 and prior may be found on the CMS website: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched