(Medicare Claims Processing Manual)

G. Family of Codes   In a family of codes, there are two or more component codes that are not billed separately because they are included in a more comprehensive code as members of the code family.  Comprehensive codes include certain services that are separately identifiable by other component codes.  The component codes as members of the comprehensive code family represent parts of the procedure that should not be listed separately when the complete procedure is done.  However, the component codes are considered individually if performed independently of the complete procedure and if not all the services listed in the comprehensive codes were rendered to make up the total service.  H. Most Extensive Procedures   When procedures are performed together that are basically the same or performed on the same site but are qualified by an increased level of complexity, the less extensive procedure is bundled into the more extensive procedure.  I. Sequential Procedures  An initial approach to a procedure may be followed at the same encounter by a second, usually more invasive approach.  There may be separate CPT codes describing each service.  The second procedure is usually performed because the initial approach was unsuccessful in accomplishing the medically necessary service.  These procedures are considered sequential procedures.  Only the CPT code for one of the services, generally the more invasive service, should be billed.  J. With/Without Procedures   In the CPT manual, there are various procedures that have been separated into two codes with the definitional difference being with versus without (e.g., with and without contrast).  Both procedure codes cannot be billed.  When done together, the without procedure is bundled into the with procedure.  K. Laboratory Panels  When components of a specific organ or disease oriented laboratory panel (e.g., codes 80061 and 80059) or automated multi -channel tests (e.g., codes 80002 -  80019) are billed separately, they must be bundled into the comprehensive panel or automated multi -channel test code as appropriate that includes the multiple component tests.  The individual tests that make up a panel or can be performed on an automated multi -channel test analyzer are not to be separately billed.  L. Mutually Exclusive Procedures  There are numerous procedure codes that are not billed together because they are mutually exclusive of each other.  Mutually exclusive codes are those codes that cannot reasonably be done in the same session.  An example of a mutually exclusive situation is when the repair of the organ can be performed by two different methods.  One repair method must be chosen to repair the organ and must be billed.  Another example is the billing of an initial service and a subsequent service.  It is contradictory for a service to be classified as an initial and a subsequent service at the same time.  CPT codes which are mutually exclusive of one another based either on the CPT definition or the medical impossibility/improbability that the procedures could be performed at the same session can be identified as code pairs.  These codes are not necessarily  linked to one another with one code narrative describing a more comprehensive procedure compared to the component code, but can be identified as code pairs which should not be billed together.  M. Use of Modifiers  When certain component codes or mutually exclusive codes are appropriately furnished, such as later on the same day or on a different digit or limb, it is appropriate that these services be reported using a HCPCS code modifier.  Such modifiers are modifier s E1 -  E4, FA, F1 -  F9, TA, T1 -  T9, LT, RT, LC, LD, RC, - 58, -78, -79, and - 94. Modifier - 59 is not appropriate to use with weekly radiation therapy management codes (77427) or with evaluation and management services codes (99201 - 99499). Application of these modifiers prevent erroneous denials of claims for several procedures performed on different anatomical sites, on different sides of the body, or at different sessions on the same date of service.  The medical record must reflect that t he modifier is being used appropriately to describe separate services.  30.1 - Digestive System (Codes 40000 - 49999)  (Rev. 3368, Issued: 10- 09-15, Effective: 01 -01-16, Implementation: 01- 01-16)  A.  Upper Gastrointestinal Endoscopy Including Endoscopic Ultrasound (EUS) (Code 43259)   If the person performing the original diagnostic endoscopy has access to the EUS and the clinical situation requires an EUS, the EUS may be done at the same time.  The procedure, diagnostic and EUS, is reported under the same code, CPT 43259.  This code conforms to CPT guidelines for the indented codes.  The service represented by the indented code, in this case code 43259 for EUS, includes the service represented by the unintended code preceding the list of indented codes.  Therefore, when a diagnostic exa mination of the upper gastrointestinal tract including esophagus, stomach, and either the duodenum or jejunum as appropriate, includes the use of endoscopic ultrasonography, the service is reported by a single code, namely 43259.   Interpretation, whether by a radiologist or endoscopist, is reported under CPT code 76975- 26.  These codes may both be reported on the same day.  B.  Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)   An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon- small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier  -53.  (Code 44388 is valid with modifier 53 beginning January 1, 2016.)  The Medicare physician fee schedule database has specific values for codes 44388 -53, 45378- 53, G0105- 53 and G0121- 53.  An incomplet e colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy.  Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one -half the value of the inputs for the codes. 30.2 - Urinary and Male Genital Systems (Codes 50010 - 55899)  (Rev. 1, 10- 01-03) B3-15200  A. Cystourethroscopy With Ureteral Catheterization (Code 52005)  Code 52005 has a zero in the bilateral field (payment adjustment for bilateral procedure does not apply) because the basic procedure is an examination of the bladder and urethra (cystourethroscopy), which are not paired organs.  The work RVUs assigned take  into account that it may be necessary to examine and catheterize one or both ureters.  No additional payment is made when the procedure is billed with bilateral modifier  -50.  Neither is any additional payment made when both ureters are examined and code 52005 is billed with multiple surgery modifier  -51.  It is inappropriate to bill code 52005 twice, once by itself and once with modifier  -51, when both ureters are examined.  B. Cystourethroscopy With Fulgration and/or Resection of Tumors (Codes 52234, 52235, and 52240)  The descriptors for codes 52234 through 52240 include the language tumor(s).  This means that regardless of the number of tumors removed, only one unit of a single code can be billed on a given date of service.  It is inconsistent to allow payment for removal of a small (code 52234) and a large (code 52240) tumor using two codes whe n only one code is allowed for the removal of more than one large tumor.  For these three codes only one unit may be billed for any of these codes, only one of the codes may be billed, and the billed code reflects the size of the largest tumor removed.   30.3 - Audiology Services  (Rev. 2044, Issued: 09- 03-10, Effective: 09 -30-10, Implementation: 09- 30-10)  Section 1861(ll)(3)of the Social Security Act (the Act) defines audiology services as such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as would otherwise by covered if furnished by a physician.  In this section, these hearing and balance assessment services are termed audiology services, regardless of whether they are furnished by an audiologist, physician, nonphysician practitioner (NPP), or hospital.  Because audiology services are diagnostic tests, when furnished in an office or hospital outpatient department, they must be furnished by or under the appropriate level of supervision of a physician as established in 42 CFR 410.32(b)(1) and 410.28(e).  If not personally furnished by a physician, audiologist, or NPP, audiology services must be performed under direct physician supervision.  As specified in 42 CFR 410.32(b)(2)(ii) or (v), respectively, these services are excepted from physician supervision whe n they are personally furnished by a qualified audiologist or performed by a  nurse practitioner or clinical nurse specialist authorized to perform the tests under applicable State laws.   References to technicians apply also to other qualified clinical staff.  See Pub. 100- 02, chapter 15, section 80.3.D.   A. Correct Reporting   1. General.  Contact the A/B MAC (B) for guidance if the CPT codebook changes the description of codes mentioned in this section.  Other policies concerning audiological services are found in Pub. 100- 02, chapter 15, section 80.3.  See chapter 26 of this manual for place of service and type of service coding.  Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105- 33), which added section 1834(k)(5) to (the Act), required that all claims for certain audiology services be reported using a uniform coding system.  CMS chose HCPCS (Healthcare Common Procedure  Coding System) as the coding system for the reporting of these services.  This coding requirement is effective for all claims for audiology services submitted on or after April 1, 1998.  The BBA also required payment under a prospective payment system for audiology services.  Effective for claims with dates of service on or after January 1, 1999, the Medicare Physician Fee Schedule (MPFS) became the method of payment for audiology services  furnished in the office setting and for the associated professional services furnished in physicians office and hospital outpatient settings.   2. Use of the NPI.  For audiologists who are enrolled and bill independently for services they render, the audiologists NPI is required on all claims they submit.  For example, in offices and private practice settings, an enrolled audiologist shall use his or her own NPI in the rendering loop to bill under the MPFS for the services the audiologist furnished.  If an enrolled audiologist furnishing services to hospital outpatients reassigns his/her benefits to the hospital, the hospital may bill the A/B MAC (B) for the professional services of the audiologist under the MPFS using the NPI of the audiologist.  If an audiologist is employed by a hospital but is not enrolled in Medicare, the only payment for a hospital outpatient audiology service that can be mad e is the payment to the hospital for its facility services under the hospital Outpatient Prospective Payment System (OPPS) or other applicable hospital payment system.  No payment can be made under the MPFS for professional services of an audiologist who is not enrolled.  Audiologists must be enrolled and use their NPI on claims for services they render in office settings on or after October 1, 2008 (for additional information about enrollment, refer to Pub. 100-08, Medicare Program Integrity Manual, chapter 15).  Before October 1, 2008, the services of audiologists who were not yet enrolled in Medicare were billed by a physician or group who employed the audiologist.  Audiologists shall use the billing instructions in the Medicare manuals; for example, see this manual, chapter 1, section 30.  See the most recent MPFS for pricing and physician supervision levels for audiology services:  http://www.cms.hhs.gov/PFSlookup/01_Overview.asp#TopOfPage.  The NPI of the supervising physician shall be used to bill audiology services when supervision is appropriate.  The most recent OPPS pricing for audiology services is available in Addendum B at:  http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage.