Challenges of Gastroenterology Billing

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.

Reducing Your Gastroenterology Billing Errors

Appropriate Use of E/M Codes

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. 

Appropriate Use of Modifiers

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.

Using Accurate Diagnosis Codes

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.

Ensure Proper Documentation

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).

Common Gastroenterology Billing Errors

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:

  • Control of bleeding is included in endoscopic procedures and is not separately billable unless the patient comes in faculty with GI bleed. The control of bleeding by colonoscopy is coded with CPT code 45382. Append the -78 modifier to the CPT code for the return to the OR for control of bleeding procedures. The physician examines the colon and rectum using a colonoscope to identify the source of internal bleeding. He then controls the bleeding in the colon by various methods. CPT code 45382 is listed under ‘Endoscopy Procedures on the Rectum’.
  • Incomplete or failed colonoscopies should be coded properly with G-Code with the -52 or -74 modifier, Modifier indicates the discontinued procedure. You can refer to payer-specific coding guidelines for the correct use of modifiers.
  • If during Esophagogastroduodenoscopy (EGD) procedure, a lesion is biopsied and subsequently removed during the same procedure, then you can only bill removal of the lesion. The biopsy will be considered an incidental procedure and should not be separately billable. If the lesion is removed using a different method during the same procedure, then you can code biopsy and lesion and removal of the separate lesion with the appropriate modifier (modifier -59).

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:

Published By - Medical Billers and Coders
Published Date - Oct-11-2022 Back

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