Gastroenterology billing and coding is complex and challenging as Gastroenterologists provide both medical and surgical services. Accurate, efficient billing and coding for Gastroenterology services ensure the survival of practice amidst various challenges like the COVID-19 pandemic. As per a recent Gastroenterologist compensation report, 52 percent of self-employed gastroenterologists saw a 1 to 25 percent decline in patient volume that they consider permanent. Such stats highlight the need of utilizing every rightful opportunity to collect reimbursement for Gastroenterology services. Due to the complex nature of Gastroenterology billing, Revenue Cycle Management (RCM) team tends to make billing errors. Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing services. We can help you in reducing Gastroenterology billing errors which would help you to collect more while staying compliant with billing guidelines.
Evaluation and management (E/M) codes are assigned based upon two elements i.e., time and medical decision-making (MDM). Due to changed guidelines for evaluation and management codes, billers often make mistakes while using Gastroenterology E/M codes 99202-99215. Effective from the year 2021, the definition of time associated with 99202-99215 changed from ‘typical face-to-face time’ to ‘total time spent on the day of the encounter.’ Billers need to be careful while using these E/M codes and keep in mind that the aim of this change is to clarify times when more than one provider is involved.
Modifiers indicate that a service or procedure performed has been altered by some specific circumstance, but not changed in its definition or code. They are used to add information or change the description of the service to improve accuracy or specificity. In some cases, inexperienced coders use modifiers to receive increased insurance reimbursement. Such billing practices are considered malpractices leading to false billing and could result in external payer audits or heavy penalties. The gastroenterology billing team often confuses between modifier 51 (i.e., multiple procedures) and 59 (i.e., distinct procedural service).
Though both modifiers are used when multiple services are performed they serve different purposes. Modifier 51 is used to identify the second and subsequent operative procedures to third-party payers when the procedures are ranked in order of RVU and are not added to the primary procedure based on what was done to address the patient’s illness. On the other hand, modifier 59 is used for the different sessions or encounters on the same date of service; different procedures distinct from the first procedure, different anatomic sites, and separate incisions, excision, injury, or body part.
Selected diagnosis (ICD-10) codes must support medical necessity for the services provided. While physicians need to document the most specific clinical diagnosis, medical coders should assign diagnosis codes to the highest degree of specificity documented. Choosing inaccurate diagnosis codes could lead to claim rejections and might delay reimbursement. In a situation where the Gastroenterologists cannot establish a diagnosis for an encounter, the condition or conditions such as symptoms, signs, abnormal test results, or other reasons for the visit, should be coded to the highest degree of certainty. Comorbidities can be coded to support a higher level of decision-making.
Failure to demonstrate medical necessity could lead to denied claims and authorization denials for lab tests, medication, diagnostic studies, etc. Government payers like Medicare and private payers have local coverage determinations (LCDs) for many procedures and testing, including indications and restrictions, along with approved diagnosis codes. Documentation is an area where most Gastroenterology billing team fails to prove medical necessity or to justify procedure (CPT) code selection.
When it comes to billing diagnostic studies and procedures, medical necessity/indication for the testing must be documented. Usually, abnormal lab tests, signs, and symptoms are the most crucial red flags for testing. Your documentation must include the interpretation of the test results along with recommendation(s).
As mentioned earlier, Gastroenterology billing and coding is complex and challenging as Gastroenterologists provide both medical and surgical services. Below we listed some of the common Gastroenterology billing errors and ways to avoid them:
Medical Billers and Coders (MBC) is well-versed with gastroenterology billing and endoscopy billing. Our team of Gastroenterology medical billing and coding specialists works hand-in-hand with your practice to ensure you receive accurate reimbursement for delivered services. To know more about our Gastroenterology billing and coding services, contact us at: 888-357-3226 or drop an email at: firstname.lastname@example.org.