All right, so what we're going to talk about now is mancillary services, MAC versus moderate sedation, the data service and diagnostic studies and pathology services, pathology reporting, documentation requirements for diagnostic, medical and nutrition therapy and infusion injection services. There's a lot of talk in this section. So I'm going to start with anesthesia billing. And I think most of you know the difference between it, so I'm really not going to spend a lot of time on the anesthesia levels themselves. But MAC, all right, we're talking about cRNA anesthesia billing. And since January 1st of 18, we have basically five codes that pertain to GI, 00731, 00811, 00812, and 00813. Then we look at moderate sedation, which we always consider as conscious sedation. And that's a drug-induced depression of consciousness. And this is usually billed by our doctors that are monitoring the patient through their own endoscopy services. And it does require the presence of a trained professional. The code we actually are looking more at is G0500. That's specific to GI endoscopic procedures. So the anesthesia codes, what I just kind of talked about for our MAC, 00731 is upper GI endoscopic procedures, and the base fee is five units. Now the current conversion factor is $21.56. For 2022, it is $21.04. Now this conversion factor does, it changes. This is just the national. It's based upon your locality again. So when you go into the anesthesia fee schedule that's published on the CMS site, it'll be under your state and your locality, is to know what your actual conversion factor that you would use in your practice. 00732 is for ERCP, and that's a base unit of six. And that's only if you're really doing these in your ASC. 00811, anesthesia for lower endoscopic procedures. This is base units of four. So this is other than screening, because we have a code specifically for screening colonoscopy. And that's 00812. And when you look at the definition, it says it's to describe anesthesia for any screening colonoscopy, regardless of ultimate findings. The base unit for this is only three. 00813, this is for doubles. And these codes were all new in 2018. And it starts as a base unit of five. So an upper and a lower done on the same day. So 00811 is used on patients undergoing diagnostic colonoscopies, patients with symptoms, abnormalities, and chronic diseases. Now, per CMS instructions, if you start as a screening colonoscopy and you convert to a surgical colonoscopy, you would add a PT modifier and you're able to bill 00811, even though that 00812 states, regardless of findings, CMS allowed that the anesthesia start at four units for those patients that start as screening and convert to a surgical. But remember, with that PT modifier, the patient will still be responsible for the 20% at this point in time. Now, most commercials do not follow CMS policy. And even if you find a polyp, you still would use 00812. Now some commercial payers want this code used on patients with a personal history of colon cancer, colon polyps, because they consider their surveillance diagnostic and not screening. So recommend that you have a spreadsheet for those of you built for anesthesia services to know which payers want what category based upon their presenting problems and what happens during the procedure. So the rule of thumb for 00812 for Medicare is, if you're going to bill a G0105 or G0121 for the physician, then you're going to use 00812 for the commercial site, for their anesthesia site. 00813 is used on patients undergoing doubles for EGD and colonoscopy. There's no additional guidance on this. It does not accept a 33 RPT modifier. And so, unfortunately, this may be subject to patient co-pays and deductibles. Even though you might want to try and use screening on the first position, that doesn't necessarily mean it's going to trigger preventive services. All right, so not all payers remove the anesthesia work value from the physician fee schedule. All right, so on the conscious sedation charges, all right, you may not get paid separately for this. So in 2017, where we actually got the ability to start billing for our sedation services for conscious sedation or moderate sedation, Medicare took that anesthesia work value out to allow for those providers that manage their own anesthesia to bill separately for that. But not all of our commercial payers did. And so it doesn't, you know, so some payers are just not going to pay for it. Medicaid will not cover it, all right. Some of our commercial payers will, some will not. Now some payers, including Medicare, do not approve MAC charges unless the patient is ASA-3. So you've got to know what your guidelines are for each individual payer. Make sure that comorbidities and risk factors are well documented as reasons for MAC in the anesthesia risk assessment. So the anesthesia provider is responsible for that to determine the level of complexity for that patient. So what is the reason for MAC, all right? And some payers require these diagnoses in the primary position to support the medical necessity for MAC. So again, spreadsheet, which for diagnosis code goes primary? Does it go as the reason for the procedure or the finding? Or does it go for the reason for MAC? G0500, this is the code that specifically states, moderate sedation services provided by the same physician or other qualified healthcare professional performing a GI endoscopic service that sedation supports. So this is patient age five and older. And it says additional time may be reported with 99153, and that's each additional 15 minutes. All right. 99153, the problem with that is that it is only payable by Medicare when the place of service is 11, which is office. A lot of you do not do office-based endoscopy. So G0500 may be the only code that you will get reimbursement for. All right. So since July 1st of 2017, and that's why I keep stating the G0500 is your code to utilize, the CCI edits bundle code 99151 and 99152, which are conscious sedation codes not specific to GI because there is a specific code for moderate sedation for GI procedures. All right. So we had a little glitch in the system between July and August when the CCI edits came out. And most payers after that did update their policies to accept the G0500 code. If you are still not getting paid with the use of G0500 code, don't automatically submit 99152 with a 59 modifier, only unless your payer gives you specific written policy to support that. So moderate sedation time issue. All right. You have to have at least 15 minutes in the description, but CPT instructs only to build the anesthesia time is at least 10 minutes in duration. So the start time is when the first push is given with the physician present in the patient room and the stop time is when either the patient or the physician leaves the room after the procedure. It is not scope in and scope out. So make sure that your docs as well as your nurses, whoever is doing the documentation in the diary of care knows what the start and stop time is. Now physical status modifiers. These are for anesthesia services only, not for conscious sedation services. So P1 is class one, which is a normal healthy patient. P2 is class two with somebody that has mild systemic disease. And this is the most common patient we see is P2. P3 is a patient with severe systemic disease. All right. And this gives you some examples. And then we have P4, which is a patient with severe systemic disease that is constant threat to life. So remember what I was talking about with UnitedHealthcare earlier about the presence of stents in the recent episode, less than three months is ASA4, greater than three months is ASA3. So it's so important. It is so important as to your providers documenting that past history for the patient. So if, here's a question. So I talked about it in the first session and again, just a little bit ago. If a patient has a history of an MI two months ago, what ASA category would be assigned? Is it ASA2, ASA4, ASA3, or ASA1? Okay. So 14% say ASA2, 38% say ASA4, and 48% say ASA3. The answer is ASA4. So if I go back to the previous slide on here, we'll go back to that. Examples include for ASA4, recent less than three months history of MI, CVA, TIA, or coronary disease, ongoing cardiac ischemia, severe valve dysfunction. I mentioned that earlier when we were in the first session with the UnitedHealthcare and the place of service issue that they stated that the place of service outpatient hospital would be appropriate for ASA4 patients. So somebody that's had a history of MI within the past three months. So remember, so important for your providers to document. This is also important if you've got a patient in the office that is coming in and your nurses or your medical assistants are taking the history and the patient said that they had a stroke or they had a heart attack, when did they have that? So the documentation requirements for anesthesia, and you have to have your basic demographic information. You need to have the patient's diagnoses. You have to have the pre-anesthesia risk assessment in detail, the procedure performed, the findings on the diagnoses to support medical necessity for anesthesia, comorbidities should be listed in order of priority and submitted on the claim. That is the most common reason for denial of anesthesia services is lax medical necessity. All right, so it is so important that our anesthesia providers give us that information to build. And then there's physical status, the type of anesthesia, position of the patient, starting end time, which is different than the start and end time for conscious sedation. So start and end time for anesthesia begins with the anesthesiologist prepares the patient for induction. And the time is started from the moment the anesthesia provider places monitor, starts the IV and begins to administer any type of preoperative sedation or other medication. So any discontinuous time and obviously the name of the anesthesia provider. And if you have an anesthesiologist supervising the CRNA, the name of the CRNA and the name of the anesthesiologist have to be on the medical record. And obviously you have to have a legible form of the name and credentials and electronic signatures must indicate it's electronic signature. And I think that's for everybody for any type of documentation in our medical record, not just pre-anesthesia. So this is really an important link. It's actually for signatures and signature requirements. And this applies not just to anesthesia, but any type of documentation in our medical record. All right. So for modern sedation, for our GI docs, we still have to do any anesthesia risk assessment. We still have to do a problem focused examination prior to the procedure in a pre-sedation assessment form. And we need to immediately pre-do an assessment prior to the first sedating doses and initiation of any type of access and fluids. All right. So I already told you when the start time is, when the GI physician is in the room, and it begins with the administration. It requires the face-to-face attendance of the physician, and it requires the presence of an RN to monitor the patient. All right. This is an example, and this is best practice documentation for sedation services. So you have your patient's name and procedure, and you have the documentation of the sedation, the start time and the stop time. And it also has the name of the independent professional documented in the notes. We have a couple of payers that routinely will either append a claim or do a post-payment review on sedation services. So the information should be in one spot, and preferably it should be in your endoscopy report. So this is one example, and the next example is similar. All right. So it's a little bit more structured than the other one. Okay. So make sure that your anesthesia provider gives you both the primary as well as the indication and findings during the procedure. And again, make sure that you have a spreadsheet. Check your Medicare LCDs frequently. There's one major payer out there, and there's actually – it'll take you to CMS's site, but it is Novitas that has a specific anesthesia policy that has over 24 pages of approved ICD-10 codes for MAC, and most of them are strictly comorbidities and risk factors. All right. Check your commercial payers frequently for any changes, and make sure that you audit the documentation frequently. All right. Make sure that conscious sedation is verified and at least 10 minutes of sedation time is documented. This can be difficult on EGDs that sometimes are five and eight minutes long. So again, so important for you to know the start and the stop time in there. Okay. The date of service for diagnostic studies and pathology services. So published in effect on February of 2019, practices are to report claims for procedures submitted with modifier 26, which means that's your interpretation, on the date of interpretation, modifier TC, which is the technical component on the date of service, which is usually the placement, and then no modifiers if you report it as a global service with either the date of placement or the date of interpretation. Now that's CMS policy. Now as far as your commercial payers, sometimes they follow CMS, but they also may have their own policy, and again, it's better to check with each payer and create a spreadsheet with payer guidelines. It seems that the majority of payers follow the date of service and placement, all right, the same as the TC modifier. Okay. So another question. When you're billing for interpretation services for esophageal manometry, what date of service is used for Medicare? So this is modifier 26. Is it the date of swallow? Is it either the date of interpretation or the date of swallow? Is it the date of interpretation, or is it none of the above? Break it down a little bit. We've got date of swallow, 32%, either the date of interpretation or data swallow, or the date of interpretation, which is 56%, and it is the date of interpretation C. So this is for Medicare. If you're billing for interpretation services only, with modifier 26, it is on the day of interpretation. So important for your providers to have two dates documented on their records, the date of service, as well as signed and dated. All right, so pathology report documentation requirements. All right, we have to have the name and location of the facility. All right, and if the pathologist is billing with the 26, which means the interpretation only, there should be a report with his or her practice name at the top of the report. If the lab is billing separately with the TC, then the lab's name should be on the top of the report. And if it's billed as a global service, which means no modifiers, all right, then the name of the practice should be on the top of the report. And I mean, just like with anything, we have to have patient demographic information. We have to have the date the specimen is obtained, the date the specimen was received, and the date the specimen was processed. So three dates are required on the pathology report. The ordering physician is usually the endoscopy provider. The referring physician can be the endoscopy provider if the patient was self-referred, or actually the referring provider. So those are the requirements that need to be on pathology. Now the clinical reason in the clinical history is so important. So it's usually the reason for the endoscopic procedure, and it should be specific. It can be based on symptoms, personal history, family history, et cetera. If there's no clear indication, then we should be looking at the endoscopy report, because normally what's on the path report comes from the endoscopy report or the requisition. So if there is, this becomes a really frequent issue, then you need to speak with the endoscopy lab to ensure more specific detail be entered on the pathology requisition forms. And it also can be a physician issue if the requisition is being generated from the endorider in particular. We have to have the location of each specimen. We need to have the indications for stains, what you're ruling out. Their stain types are listed, and there actually are more stain types than this in particular, but these are the most common ones we see. There has to be a microscopic description, and that's the pathologist will always perform this. The size and margins, the number of units and specimens, the gross description, which is how it looks to the naked eye, and it usually includes the size, the color, the number of samples, et cetera. This can be done by the tech or by the pathologist. There needs to be a diagnosis section, gives you the final diagnosis, and oftentimes there can be a synoptic report that can say, and one of the most common ones is, well, this is very suspect it's an IBD, however clinical correlation is required. So that means you check with your doctor, you know, do you believe this is IBD or not? And sometimes your doc doesn't know, and there's a diagnosis code for this one, that's indeterminate colitis, and that's a good appropriate indication. So then we have to have the data, the significant pathologist as well as the date of interpretation. The special focus on stains by most Medicare carriers, and for those of you guys that have listened to us before on this, this is not new. This came out a long time ago, all right, and most of our LCDs in different, in all of our states have guidelines for this. They just want to make sure that this is not just a routine stain, right, and that ordering special stains prior to the review of the routine stain is not reasonable and necessary. So make sure that your pathologists are aware of this, and I think most of them are, all right, but the payers, specifically Medicare, does monitor the amount of stains associated with specific specimens, and most of them, ones that they monitor, are those associated with upper GI endoscopy procedures. All right, so just make sure that that you look through these guidelines, make sure that your pathologists, providers, and administrative staff are aware, make sure that they're clear indications and reasons for stains. All right, make sure the diagnosis codes are assigned to each stain, they're linked to the specimen that's being billed. That's so important, and I know Kristen was talking about ICD-10 codes and being the most important code assigned to the claim, and absolutely that is. It establishes medical necessity, so you just don't want to run ABCD through everything. So you got four things reported and ABCD is listed next to each one of them? No. All right, usually they're, especially on endoscopic procedures, if you found, did a polypectomy, my snare of the sigmoid, and it came back as an anemone, then D12.5 is what you would assign to the, to the snare polypectomy, and if you biopsied the transverse and it came back as a hyperplastic polyp, then you can assign K63.5 for the biopsy. You can report them on separate line items, you can't report them on the same claim. For colonoscopies, when screening is the indication for the procedure, this should be the primary diagnosis in order to trigger preventive benefits. However, there are some payers that do not allow a screening diagnosis as a primary for any pathology services, so utilize your comment field if they do not allow it, and that's box 19. So you can say, starting a screening converted to diagnostic, because remember, if the ACA guidelines are followed and it starts as a screening colonoscopy, then they should pay this at 100% with no out-of-pocket responsibility from the patient, and modifier PTR33 is not allowed on any pathology claims. All right, so 88305, 312, and 313, some of these are, these are our stains on our basic H&E, they're building units, all right, and some payers have their own policies on this. 88342 is for an immunostain, and so there's specific guidelines for immunostains, all right, so 88342 is the first code for stain to a single specimen. If multiple immunostains are used on the same specimen, then we have to utilize 88341 for each additional stain to that same specimen. I think these are just the other, the pearls of wisdom. Make sure that your lab and pathologists are credentialed. Your taxonomy code should be 15. Make sure that your diagnosis codes are assigned, and make sure that your report is signed and considered complete before submitting charges. All right, these are some just also guidelines for assigned RVUs with modifier 26 and TC and global, just what we talked about before, and as always, don't hesitate on asking questions, and also don't rely on the CPT codes and diagnosis codes on your bottom of your pathology report, they're not always correct, and it's the same, goes with the same things on your endoriders as well. Just because they're on there doesn't mean that they're correct. Diagnostic studies need the same guidelines. You need demographics, you need the dates the test was started or the device was placed. Date of download is preferred, but very rarely ever seen on the note. Indication for the procedure, the description, the date of interpretation, the signature of the interpreting physician, so there are two dates that have to be on diagnostic studies. The date the service was done, the device was placed, as well as the date of interpretation with the signature, and then any type of pertinent data like waveform swelling studies, any additional images need to also have appropriate patient information documented on every page of the study. These are just GI-specific studies, all right, radiology services, capsule endoscopy. There are some bundling issues with this, so as of January 1st of 2015, endoscopic placement of the capsule is not separately payable unless it's done for diagnostic or therapeutic purposes. All right, if we are interpreting a capsule study that was not done in our office setting, then we add a modifier 26 to that. The place of service is where the capsule was swallowed or where the device was placed. If the LEM is not visualized, modifier 52 should be added on the capsule code. So, remember, providers must document medical necessity as to why the capsule had to be placed endoscopically, so if there's an issue with dysphagia, if there's an issue with gastroparesis, is there a gastric outlet obstruction, there has to be a reason why you did endoscopy at the time of the capsule. Same for the Bravo, all right, so the EGD is considered part of the Bravo placement as well, unless it's truly done for diagnostic purposes, so it is up to our doctors to indicate the reason for the EGD. All right, so should you be verifying eligibility on all diagnostic studies? Yeah, not everybody's going to approve the Bravo, and for capsule studies itself, they have certain guidelines and indications and documentation requirements. The difference between FibroScan and liver ultrasound, all right, is that there is no ultrasound component with FibroScan. Be specific as to the diagnosis code to make sure symptoms are submitted if the condition is being ruled out. If there is no indication and finding on the any of those diagnostic studies, it cannot be billed. If it's not dated and signed, it cannot be billed. All right, when billing two separate diagnostic procedures, make sure that different devices are utilized when appropriate, and again, routinely check LCDs for policy changes. All right, nutrition and weight loss services, and I know that a lot of you listening do have registered dieticians in your office, and if you don't, your weight loss or your nutrition services can also be done by your advanced practitioners as well as your doctors, and that's usually based upon time. All right, so there are medical nutrition codes, and unfortunately, Medicare does not recognize these codes for conditions other than diabetes and renal disease. There's a link in here that goes more into CMS on that, and I think a lot of you that do have registered dieticians in our office do utilize their services as cash pay situation, and if you're wanting your patients to have a nutritional evaluation or consultation, you know, if you don't do it, they're going to have to go to the hospital. Your charges are usually less. They're more apt to be happier coming to you to have it done, and so as long as they know that they're going to have to pay for it regardless of where they go, you shouldn't have as a difficult as a problem trying to collect on that. There are some counseling specifically for obesity, all right, but they're not only payable to providers employed by these specialties, and you know, it's like, oh, we have MPs and clinical nurse specialists in our practice and PAs. Yes, but they're under the auspices of gastroenterology, and so it's not going to be a covered service on this. All right, infusion services. All right, guys, this is a big problem area for us, and trying to get paid timely on this, so I'm just going to briefly go through this. Chemotherapy administration is what we utilize when we bill for Remicade, all the generic Remicade codes that we have now. We can also do this for Antivio and Stellera, et cetera, all right, and these are usually highly complex, and they require direct supervision, so they're for the administration of antineoplastic drugs and certain monoclonal antibodies, right, and like I said, these require direct physician supervision. We also have therapeutic and diagnostic injections and infusions. They also require direct supervision, and that's one of the comments that a lot of questions that we answer is, do our doctors, our billing providers have to be in the place-of-service office? Yes, they do. That's what direct supervision means. Then there are hydration codes that you can bill separately, but it has to be separate from the Remicade infusion, et cetera, and the patients are dehydrated or they have hypoglycemia. It's not with it. It's outside of it, right, so it's a separate half an hour or hour in addition to it, so an infusion is defined as any substance greater than 15 minutes, all right, and up to one hour, and direct supervision, which is response, which is the guidance and the guidelines for any of our infusions and injections. It means that a physician's presence is required in the office suite, place-of-service 11, and must be immediately available to furnish assistance and direction during the performance of the procedure. The physician does not have to be present in the room when the procedure is performed, but they have to be in the office suite, not in the endoscopy center downstairs or next door, in the office suite, so true or false, the supervising physician is the provider who is in the office suite during the entire infusion. 74% is true. It's absolutely, this is absolutely true. They have to be there during the entire infusion, all right, is the provider, the supervising provider, is the provider that you're going to bill under that day. They have to be there through the entire infusion. Okay, on infusions, do you have documentation in the record to support the reason for the initiation and change of the biologic agent? This is very important, guys, because this is one of the reasons that we get our claims pended. You know, be specific as to lab studies, patient signs and symptoms. Payers are requesting records both at the time of pre-op and after claim submission. So, do you have the specific IBD condition documented? And there, again, have been pending payment if the diagnosis of Crohn's or Ulcerative Colitis is not specific. So, whoever's doing your diagnosis, do you have not specific. So, whoever's doing your documentation for infusion services, and it's usually your nurses, make sure that they are aware that they have to be specific, all right. Why are you billing a visit on the same day of the infusion? Was it medically necessary? That's one of the issues. If you're just seeing how the patient's doing and you're not doing anything other than that, that is considered part of the infusion service and not severally payable. Do you have the current order for the medication with name, dose, and frequency documented on the infusion record or on the patient chart? We've had a couple practices that have gotten pulled in for review by RAC on this, and they actually were recouping because there was no order stated on the infusion record, but they actually did have it in the patient chart. So, this is just a pearl here that makes sure that if you get requested records, you know, the payers are looking for the order, and if it's separate from the infusion record, you need to make sure and pull it and send it along if records are requested, and it just can't be 100 milligrams, all right. It has to be milligrams per kilogram usually. The name of the referring provider also should be the ordering provider in your practice, not the PCP. That was another one. This was a Novitas request on this one where they actually said it was not an Incident 2 service. Remember, Incident 2 means you sell the patient first and you planned the treatment plan for this patient, all right. So, the ordering provider should be in the referring provider box on the 1500 form, not your PCP. Okay.

ancillary services

MAC

billing codes

documentation requirements

nutrition therapy

coding

hydration codes