So, this right now is basically going to be a summary of our top coding and reimbursement issues that we talked about today, but as it impacts physicians as well as facilities. So we're going to talk about OIG and RAC issues just a bit. Kristen actually talked a lot about the OIG. I'm going to talk about a little bit of some other issues that they're looking at too. Implementation of the medical record signature requirements, ICD-10 specificity, again back to substantiation of medical necessity, multiple endoscopy billing, hemorrhoid banding issues, and understanding modifier 25. So let's go to OIG and RAC. So these are the top issues, actually, the revised work plan for 2021, and they're looking at billing for services not rendered or not provided as claimed. And so orders, remember when I was talking about orders, is there a current order for a capsule study? You know, so we got the capsule report, but is there an order for it? And also, you bill the charge, but we can't find the report anywhere. So remember to make sure, you know, look for two things. Make sure we see the order, make sure that we see the medical necessity for the order, and then of course, make sure we have actually got the report. Getting claims for equipment, medical supplies, and services that are not reasonable and necessary. Knowingly misusing provider identification numbers, which results in improper billing. Every once in a while, we get questions on this. So a new provider is not credentialed. The practice administrator works around the delay in credentialing by billing services under the idea of another provider in the practice who is already credentialed. You know, you got to be careful with this. This is a false claim, guys. You know, what you want to do with this is as soon as you know this provider is coming on board with you, you start the credentialing process. You know, we sometimes are allowed to do retroactive billing for Medicare for 60 days. We actually can do it for some commercial payers, and some commercial payers say absolutely not. So your scheduling staff needs to know who the provider is credentialed with. You don't set up patients with that provider who is still awaiting credentialing. All right. So again, this is an issue. Be aware that it is considered a false claim, and don't bill it under somebody else that's already credentialed. Unbundling services. So billing for services that are bundled. So making sure that your coders check CCI edits, make sure that they're using appropriate modifiers. That's the next part. Failure to properly use coding modifiers. Clustering. They're looking to see, like, we call it flatlining, that provider consistently bills all patients at a level three. All right. So, you know, it's like, well, I'm kind of afraid of billing a four, so I feel comfortable billing a three. But you can, if you're not billing to the decision-making and or time components, you might be definitely overcharging some patients and undercharging others. So for GI practices, a predominant new patient visit, if you have all your documentation, let's put it this way, your I's dotted, your T's crossed, everything detailed, you most likely should be able to bill a level four new patient for the majority of times. So you might be undercoding as far as follow-up care, definitely equal threes and fours. Upcoding the level of service provided. A provider consistently bills all liver patients at level five because they're the only provider in the region who sees liver patients. All right. So, again, just because you might be the only one that sees them doesn't mean that their decision-making for that day justifies that level five. Right. Towel health during the COVID pandemic is being looked at very closely, making sure that the documentation requirements are met and you have to have the name and location of the provider in the patient in the medical record. You have to have consent and you have to have the mode documented. So those are the requirements that have to be in the medical record. Then they're also looking at the appropriate assignment of COVID-19 diagnosis to all services. And I think you guys have heard about all this, you know, but the hospitals have really been under the gun for this, that they've assigned COVID-19 sometimes as a primary condition so that all charges are paid at 100%, there's no patient out of pocket, when technically the patient may not have had COVID as the primary issue. So I don't think we have that issue on the GI side, but they are looking at the assignment of COVID. So for a list of all the OIG items, there's a link if you want to see more. Recovery audit contractors, Kristen gave you a list of all your RAC auditors, and I'm just kind of sharing some of the issues that they're looking at. Incident to and split share billing, so it's not just OIG, it's also RACs. E&M codes build on the same as endoscopy, which is modifier 25, and I'm going to talk about that a little bit at the end. They're looking at infusions, medical necessity, and documentation requirements. And I mentioned earlier that we had a practice that underwent a RAC review for infusions from Novitas. Pathology billing, the need for special stains, medical necessity, E&M codes, the high-level codes, plus 99204. The date of service does not match the date bill. Modifiers again for RACs as well as the OIG. Signature requirements, RAC is looking at that. Procedure documentation not on the medical record. Location of lesions removed not properly documented. Method of removal not specified. So endoscopic procedures, it is vital that you document the instrument used and the location of the lesions. And if you want a full list of all the RAC topics, because it encompasses all different modes of healthcare, there's a link there for you. All right, so polling question should be our last one of the day. Periodic contractors are focusing on these special GI issues. Modifier 76. Signature requirements, medical record numbers and demographic information. Incident two and split-shared visits. Incident two and split-shared, absolutely 74% of you. That is appropriate. I think Kristen pretty well emphasized that. And signature requirements. Those are the two things that the RACs are looking at. Medical record numbers and modifier 76, not so much. I mean, obviously it could be. But the two requirements, the two main things they're focusing on are incident two and signature requirements. Good deal. Authentication of the medical record. So a record that is not properly authenticated and signed in a timely manner will be considered invalid and may be deemed to be a service that was billed and not performed, subject to recoupment. And that was published in the Meddler Manor 6698, dated April 26th of 2010. And so the contractors that review Medicare claims, and Kristen kind of went through these already. The certs, the RACs, the program safeguard contractors, the zone program integrity contractors. These guys are all looking to see if you paid inappropriately, does your documentation support the levels of service that you bill, the services that you provide, et cetera. Sign it. You have to sign your records. Definition of an attestation statement. So in order for an attestation statement to be considered valid for Medicare medical review purposes, the statement must be signed and dated by the author of the medical record entry and contain the appropriate beneficiary information. Claims reviewers will not consider attestation statements where there is no associated medical record entry or for someone other than the author of the medical record entry in question. If there are two individuals within the same group, one may not sign for the other and medical record entries are attestation statements. And if a signature is missing from an order, claims reviewer will disregard the order during the review of the claim. That one's tough. All right, ICD-10 specificity and medical necessity. So again, how many times have we said something about medical necessity today and specifically to diagnosis coding? So describe the condition. It can be the main reason a claim gets pulled for review if there's nothing to support that level of service or the service provided. It must be supported by documentation in the current note. It's coded to the highest degree of specificity. It's usually assigned from the impression and the assessment. That was a question that I got asked earlier this week. Well, what if that diagnosis is in my HPI? Well, what goes on your claim doesn't usually come from your HPI. It's in the impression and plan. That's how the EHR systems are designed. So if you want that to go on your claim and to support your level of service that day, you need to put it in your impression, make it a number one, a number two, a number three, so that it gets added to your claim that day. It can be based on signs and symptoms if you're unable to make a definitive diagnosis during the visit. You're not going to code rule-outs and suspects, all right? You're going to put down why you think the patient has those conditions. All right. Additional diagnosis codes to support increased complexity of patient care should be added to the claim, all right? Comorbidities, risk factors, document everything to support your treatment plan for the patient that day. Making sure the documentation is clear to support the submission of the claim. Obviously, to get everything to be coded correctly at 100%, we would look at the endoscopy report. We would look at pathology. We would make sure and look at everything before it submits, all right? And we know since October 1st of 2020, the payers have been ramping up reviews for nonspecific diagnosis coding. And remember, guys, what I said before, any delay in payment costs the practice at least $40. You have to figure out why it is reviewed. You have to usually resubmit a claim or start over. And if you have to talk to somebody at a payer, well, you're on hold for gosh knows how long. Multiple endoscopy billing issues, all right? The most common denial is 45380 for the biopsy billed with the SNARE, all right? Even though you might assign the appropriate modifiers on the claim, the excess or the 45380 with the biopsy and you're linking the appropriate diagnosis code, sometimes we still have to send reports to show that these were separate lesions with separate sites. Make sure that that technique for each procedure is documented. The term random biopsy has been causing payers to disallow 45380 unless the instrument is documented. And the reasoning is when you look at the description of the base code, whether it be upper endoscopy or lower, it's brushings and washings are included in the base code. So their reasoning is, well, it could have been a brush biopsy. You didn't say otherwise. So therefore, we're going to only pay you for one of them. Make sure that there are indications and findings for every lesion that's treated. And again, why would normal tissue be biopsied? Because you're something that you're suspecting is there. What are you suspecting? What are you ruling out? What symptoms did the patient have? I mentioned this earlier. Since January 1st, EGD with biopsy is bundled in the most upper endoscopic procedures. We can bill for 43239 with biopsy with the 59 or the excess modifier. When the biopsy is done outside of the dilation zone, it is imperative for our doctors to specifically document where the dilation occurred, where the biopsy sites were. And also, you guys need to be familiar as well, not just the physicians, but as coders be familiar with the instruments used. All right, ERCP with stone debris extraction and dilation. Dilation has been bundled into stone removal since January 1st of 2014. Remember, and I mentioned this earlier when we were talking about medical necessity, document the site that actually had to be dilated before you can even proceed further with stone extraction and debridement. Hemorrhoid banding issues. All right, Kristen kind of mentioned this earlier. So does your documentation requirement and documentation indicate the grade of hemorrhoids, any symptoms, previous conservative measures for hemorrhoid treatment? Remember, this is a surgical procedure. And so for subsequent treatments, is there documentation of the patient's response, any current symptoms? And again, without current indications, there's a lack of medical necessity. We've seen two payers, Blue Cross and Blue Shield and UnitedHealthcare, and also some of the Medicare Advantage plans audit this. So making sure that your documentation is clear. Also, what instrument did you use for banding? So we've got a couple of different choices for this. So there is an endoscopic banding code, 45398, for colonoscopy with band ligation, or sigmoidoscopy 45350 with band ligation. And this is an endoscopic bander, all right? So if your doctor did a colonoscopy and also did an endoscopic banding of a hemorrhoid, then you would bill 45398. But if the instrument used to document the banding is not in there, then how do we know if it was an endoscopic bander or if it's a non-endoscopic bander, like, say, for instance, the CRH Regan system, for instance. So if you're using a non-endoscopic bander, you're going to bill this as 46221. And you can bill the colonoscopy separately. Those are not bundled. So again, making sure that the instrument used is documented. Understanding modifier 25. So this means that the visit is separate from the procedure, the minor procedure that you're doing that day. So payers are revising policies on this. And remember that most procedures and therapeutic services include a certain amount of preoperative work, which does include reviewing records and getting patient consent and the examination of the patient prior to the procedure. So just because you see the patient prior to the procedure doesn't mean that you can bill a separate visit. So each payer we've been seeing over the past year or two has had some different guidelines that can be separate from CPT instruction on the use of modifier 25. So make sure that you create a spreadsheet by payer. We've got a couple of payers up in the Northeast that won't even cover a modifier 25 on the same day of the procedure. Some of them will pay at 50% of the lowest procedure, which could either be the visit or the procedure. So again, make sure that you're aware of any specific payer policies out there on modifier 25. Modifier 25 means a significant separately visible visit is billable on the same day of a procedure. So it's not like a meet me and endo visit. It's like, all right, so say the patient in the ER, the ER doctor calls you and says, so this patient's got a food impaction and you say, send them back to endo and I'll meet them there. That visit is not separately billable. The decision has already been made and you're going to be doing your routine preoperative evaluation, which is part of your endoscopy procedure. Hospital visits are not billable on the same day of the procedure, unless something is unrelated to the procedure that has been addressed. So best practice is if you are addressing a completely separate issue, your diagnosis code for your visit would be separate from the diagnosis code for your procedure if possible. All right. So submit the symptoms for the consultation. For instance, the findings for the procedure whenever possible. All right. So your E&M visit is already included in the other service when the procedure is already pre-scheduled and no other issues are addressed. The patient presents for infusion therapy and the provider just stops in to check on the patient. The hospital visits are follow-up visits on the same day as endo, unless other issues are addressed that are not related. The patient who comes to the clinic for capsule or other diagnostic testing, again, unless completely unrelated. So just because the patient is there and you walk in and say, hi, doesn't mean you can bill that bill. So again, just pay attention to all payer newsletters for any type of updated information that is out there. All right. So our last words of wisdom for the day. Begin using the excess modifier in place of modifier 59 to bypass any payer edits. As most payers recognize the ex-monitors with the exception of Medicaid and some of our regional payers. Make sure to be clear as to whether or not the patient is undergoing a screening or diagnostic colonoscopy. And I think I mentioned this earlier. Your staff answers more questions on this topic than any other. And also make sure that your patient is also aware of the benefits. Make sure documentation is clear in the endoscopic reports to support medical necessity procedures. Make sure that you have a designated staff member to keep policies updated in your office as well as communication with those changes to the appropriate personnel, including all providers. Do not forget about your providers. Make sure that your ICD-10 list of favorites is updated in your electronic medical record to make sure that your providers assign the most specific ICD-10 code. All right. Be aware of national benchmarking statistics. Compare your practice's productivity reports and take measures to achieve compliance. Train your providers. Train, train, train your providers. Make sure that all denials are worked, not just written off. And most importantly for anything, that there is an open line of communication between staff and providers. Do not hesitate to ask a question, all right? If there's a question, you know, whether it be indications, findings, descriptions, medical necessity, anything like that, you're there to help the patient, all right? Patient care is number one. So anything that impacts patient care, oftentimes a question to a provider can get you an answer. It will not delay treatment. All right. Thanks, everybody. Thanks for your participation today.

coding and reimbursement issues

physicians and facilities

Office of Inspector General

Recovery Audit Contractors

billing for services not rendered