Gastroenterology is one of highest volume ambulatory surgery center specialties. Praveen Suthrum, president and co-founder of NextServices, explains five common GI/endoscopy coding and billing mistakes and outlines steps to avoid these errors and subsequent claim denials.
1. Modifiers. One of the most common GI/endoscopy coding mistakes is caused by confusion between modifiers 51 and 59. Modifier 51 is used for two procedures in two different coding categories being performed on the same day, for example EGD and colonoscopy, according to the American College of Gastroenterology. The ACG recommends listing the code with the greatest value first, as the multiple procedure rule applies.
Modifier 59 is utilized when a different procedure is performed or a different site is addressed on the same day, which would not normally be done. The American Gastroenterological Association offers the example of a snare of hot biopsy polypectomy being performed on one lesion, while biopsy or cold polypectomy is performed on another lesion. In this case, both procedures are payable if coded with modifier 59.
2. Upcoding. "This year there seems to be an increase in scrutiny of evaluation and management codes," says Mr. Suthrum. "This trend is only going to increase." E/M codes can be used for both new and established procedures. Typically, new patients associated with higher reimbursement rate E/M codes than established patients due to greater time requirements, according to the Centers for Medicare and Medicaid Services. Upcoding can occur when a follow-up visit with an established patient is coded at a level corresponding with a new patient office visit.
3. CPT updates. The American Medical Association 2014 CPT Code set includes more than 300 changes, 84 of which affect GI/endoscopy. "Bear in mind some of the old codes have been removed or their application has changed," says Mr. Suthrum. A number of codes have been added as well. Physicians and coders need to be aware of updates to avoid denials.
4. Eligibility verification. The front office staff, though not always associated with the billing process, are an essential element of avoiding claim denials. "A lot of billing denials continue to happen because front office practices are not strong enough," says Mr. Suthrum. "The front desk is not correctly collecting patient information or not completing insurance and eligibility verification." Building strong processes around these issues is one of the best ways to avoid denials and receive correct payment.
5. Documentation and medical necessity. "Physicians need to start thinking more about accurate and clean documentation," says Mr. Suthrum. Documentation is necessary for accurate coding and billing, which leads to clean claims.
"Payers are increasingly asking for proof of medical necessity," he says. Payers are demanding to see patient medical records and physicians may not be prepared. For those not using an electronic health record, the request for medical necessity proof can be daunting. Those using an EHR may be relying on templates, which are not always accurate and oftentimes cluttered with unnecessary data.
Clean documentation becomes even more important as data transparency in healthcare grows. Medicare recently published information on 2012 payments made to individual physicians, which is available to the public through sources such as Treatment Tracker. "I foresee that sooner or later all data GI physicians bring in, including billing and coding data, could be made public," says Mr. Suthrum.
CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
More articles on gastroenterology:
Electronic documentation software for reprocessing endoscopes: Making patient safety key
19 things to know about GI compensation & satisfaction in 2014
Will CMS cover virtual colonoscopy?
1. Modifiers. One of the most common GI/endoscopy coding mistakes is caused by confusion between modifiers 51 and 59. Modifier 51 is used for two procedures in two different coding categories being performed on the same day, for example EGD and colonoscopy, according to the American College of Gastroenterology. The ACG recommends listing the code with the greatest value first, as the multiple procedure rule applies.
Modifier 59 is utilized when a different procedure is performed or a different site is addressed on the same day, which would not normally be done. The American Gastroenterological Association offers the example of a snare of hot biopsy polypectomy being performed on one lesion, while biopsy or cold polypectomy is performed on another lesion. In this case, both procedures are payable if coded with modifier 59.
2. Upcoding. "This year there seems to be an increase in scrutiny of evaluation and management codes," says Mr. Suthrum. "This trend is only going to increase." E/M codes can be used for both new and established procedures. Typically, new patients associated with higher reimbursement rate E/M codes than established patients due to greater time requirements, according to the Centers for Medicare and Medicaid Services. Upcoding can occur when a follow-up visit with an established patient is coded at a level corresponding with a new patient office visit.
3. CPT updates. The American Medical Association 2014 CPT Code set includes more than 300 changes, 84 of which affect GI/endoscopy. "Bear in mind some of the old codes have been removed or their application has changed," says Mr. Suthrum. A number of codes have been added as well. Physicians and coders need to be aware of updates to avoid denials.
4. Eligibility verification. The front office staff, though not always associated with the billing process, are an essential element of avoiding claim denials. "A lot of billing denials continue to happen because front office practices are not strong enough," says Mr. Suthrum. "The front desk is not correctly collecting patient information or not completing insurance and eligibility verification." Building strong processes around these issues is one of the best ways to avoid denials and receive correct payment.
5. Documentation and medical necessity. "Physicians need to start thinking more about accurate and clean documentation," says Mr. Suthrum. Documentation is necessary for accurate coding and billing, which leads to clean claims.
"Payers are increasingly asking for proof of medical necessity," he says. Payers are demanding to see patient medical records and physicians may not be prepared. For those not using an electronic health record, the request for medical necessity proof can be daunting. Those using an EHR may be relying on templates, which are not always accurate and oftentimes cluttered with unnecessary data.
Clean documentation becomes even more important as data transparency in healthcare grows. Medicare recently published information on 2012 payments made to individual physicians, which is available to the public through sources such as Treatment Tracker. "I foresee that sooner or later all data GI physicians bring in, including billing and coding data, could be made public," says Mr. Suthrum.
CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
More articles on gastroenterology:
Electronic documentation software for reprocessing endoscopes: Making patient safety key
19 things to know about GI compensation & satisfaction in 2014
Will CMS cover virtual colonoscopy?