Endoscopy Families Updated in NCTracks

North Carolina Medicaid has completed updating endoscopy codes in NCTracks, aligning base codes with related procedures in the same family as well as creating 3 new endoscopy families in NCTracks. The newly created endoscopy families are as follows:

Base Code	Related Procedure Codes
43191	43192, 43193, 43194, 43195, 43196
43197	43198
44380	44381, 44382, 44384

Endoscopy Pricing

A value of ‘3’ in the Multiple Procedure field on the 2019 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 (such as, 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 is reported with only its base procedure code, 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%
• 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 pay at 100%
• 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 other groups

• Follow the same method of determining the allowance for each procedure reported within a group
• Finally, compare the total allowance for each group. Pay the highest paying group at 100% and the remaining groups at 50%

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%
• 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
• Finally, the system determines the total allowance for each group and pays the group with the highest allowance at 100% and the remaining group at 50%

One endoscopy in one group reported with one endoscopy from a different group

• The system pays the highest paying procedure at 100% of the allowance
• The system pays the other endoscopy at 50% 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 pay at 100%
• 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 pay at 50%
• For the remaining endoscopies in that group, the system subtracts the allowance for the base code from the allowance for each endoscopy, and pays 50% of the difference