Allowed Amount for Multiple Endoscopy Procedures

The following example illustrates how the allowed amount is determined in cost estimation for multiple endoscopic procedures by base CPT®4 code when modifier reimbursement and multiple procedure discounts are applied.

The contract allowed amount for endoscopy procedures can be calculated as the difference between the allowed defined for the Billed CPT®4 and the allowed defined for a Base CPT®4.

In the Contract Library > Fee Schedule tab:

CPT®4 Code	Multiple Proc Discounting	Base CPT®4 Code	Allowed
45378	No	N/A	$200

CPT®4 Code	Multiple Proc Discounting	Base CPT®4 Code	Allowed
45385	Multiple Surg (Yes)	45378	$300

CPT®4 Code	Multiple Proc Discounting	Base CPT®4 Code	Allowed
45380	Endoscopy (Yes)	45378	$250

CPT®4 Code	Multiple Proc Discounting	Base CPT®4 Code	Allowed
45381	Endoscopy (Yes)	45378	$225

In the Contract Library > Modifier Reimbursement tab:

Modifier 59 (Distinct Procedure/Service) and/or Modifier 80 (Assist Surgeon) are defined to reduce the allowed amount to 25% of the amount defined in the contract fee schedule.

In the Contract Library > Multiple Procedure Discounting tab:

Multiple procedure discounting is defined to not reduce the allowed amount on the first procedure (100%) but reduce the allowed amounts on the second, third, and so on procedures (50%).

Allowed amount adjustment in the Estimate Patient Cost window: