If you document and provide proper, let's put it this way, proper documentation for medical necessity, you won't have to worry about surviving an audit. That's the key. That is the absolute key. So we're going to talk about medical necessity. We're going to talk about diagnostic EGD policies and fusion services, medical necessity for E&M, the principles of medical record documentation and endoscopy tips. And some of this we may have already discussed a bit, but I can't stress enough that medical necessity has got to be met within your records. You've got to be able to support everything you order, the levels of service that you provide and submit on a claim. Pretty well, everything has to be neatly tied in a bow. So without medical necessity, our services won't get preauthorization. And we know now that most payers require preauthorization for endoscopies, more for upper G endoscopy than ever before, for CTs, for MRIs, for capsules, for infusion services, et cetera. And if we don't have medical necessity, services won't get paid. So we get something back on an EOB that says it lacks medical necessity. That usually refers to the diagnosis code that you assign. So without medical necessity, recoupment of previously paid services will be obtained. And the top area of focus, diagnostic EGD, infusion services, hemorrhoid treatments, and Kristen kind of went over information on those before, multiple endoscopy and most common is snare and biopsy, pathology, special stains. I mentioned that earlier. Screening versus diagnostic colonoscopy and E&M services. So we're going to talk about diagnostic EGD. Multiple practices, and this is issue, have reported delay in scheduling EGDs because there's a lack of documentation in the patient's medical record regarding lack of pertinent history. We've had a couple of comments from some of our clients that said, sometimes it takes two weeks to get these EGDs on the schedule. We can't get preauthorization. And usually if it takes you that long, you're missing information in the medical record as to why the EGD is medically necessary. That means that sometimes you're going to have to have a copy of the PCP record and not always do you have that. So any pertinent labs, radiology studies, as well as a complete patient history regarding symptoms, previous treatment protocols, Kristen made a comment about GERD. GERD itself is not an indication for an upper GI endoscopy. They have to have breakthrough symptoms. They have to be uncontrolled. There has to be at least a two month history of upper GI symptoms that have not responded to treatment. So you're going to have to talk about the symptoms. You're going to have to have documentation in the medical record as to what was the conservative methods, what prescription meds, whatever the counter meds have been used, et cetera. So here's the medical necessity for EGD. And this is actually a copy of Anthem's policy. And so Aetna, Tufts, Humana, UnitedHealthcare and some others all have policies for upper endoscopy. Some have actually a list of ICD-10 codes that support the medical necessity, but most of what they give you is indications. So this is an approved indication for upper abdominal signs or symptoms, gastroesophageal reflux symptoms that persist or recur following an appropriate trial therapy for two months or more. How many of you have seen that on your EGD indication? Because that's often a dropdown for GI quick. All right. That's a quality issue, but what are the symptoms? Because if that's the only indication that you put on there and the endoscopy shows that everything's normal, what diagnosis are we going to assign? There is no code that says GE reflux symptoms. You don't even say GERD. You just say gastroesophageal reflux symptoms. All right. So what are the symptoms? Persistent vomiting of unknown cause. And that makes sense. It's indicated. New onset dyspepsia in individuals, 50 years of age of older. And the term dyspepsia, well, the diagnosis code for that is K30, but this is one of these excludes one issues that you can't report dyspepsia and heartburn together. You can't report dyspepsia and epigastric pain together. So, and if you're limited with the dyspepsia diagnosis in individuals, 50 years of age or older, why would you use that? And remember a K code pretty well means it's a GI condition, a GI origin. All right. So epigastric pain by itself is an R code. It's a symptom. Symptoms are excellent diagnosis codes, excellent codes to support medical necessity for further workup. Go with symptoms. Unexplained dysphasia or adenophagia. Signs or symptoms suggesting structural disease of the upper GI tract. And that's also a GI quick dropdown. All right. But what again are the symptoms? Anorexia, weight loss, satiety, nausea, list the symptoms. And actually more is better. List all the symptoms that are necessary. Remember pathology also has to draw from your history, from your indications, right? So if you biopsy normal tissue in the stomach or say the duodenum, for instance, and it comes back negative, why did you do a biopsy of normal tissue? There better be a symptom to explain why those areas were also biopsied and epigastric pain, satiety, nausea, et cetera, would support that. Postoperative bariatric surgery with persistent abdominal pain, nausea, or vomiting, despite counseling and behavior modification. And I know you guys do take care of patients that have had any type of bariatric surgery. It could be sleeve gastrectomy. It could be lap band. It could be ruin my gastric bypass. All right. But those are some of the criteria that if this patient has had any type of bariatric procedure, have they been following their diet, their behavior modification of the exercising with their weight loss, et cetera. Recent or active GI bleed is also an indication. Unexplained anemia due to either blood loss or malabsorption from a mucosal process. Well, that means your diagnosis code is either D 50.0, which is a chronic blood loss anemia or D 50.9, which is iron deficiency anemia, not D 64.9, which is anemia unspecified. All right. And I know sometimes you do see these patients, they come to you from the PCP, they're anemic. They don't have any iron studies to explain, you know, there wasn't a ferritin level. There weren't iron studies. So for anemia unspecified is okay for a visit, but not for an upper endoscopy. All right. Or even a colonoscopy that anemia unspecified is not an approved indication for that as well. So please make sure that you document any other additional symptoms, any other abnormalities as well for confirmation and specific histologic diagnosis of radiologically demonstrated lesions, including, but not limited to a suspected neoplastic lesion, gastric or esophageal ulcer, upper tract stricture and obstruction. So the code of abnormal CT scan of the abdomen, which is R 93.5 is not specific. All right. That means within the abdominal cavity somewhere, but if you actually have a CT scan that shows a, a defect, say are a strictured area, specifically to the colon potential lesion in the stomach and the pancreas or anything like that, use the specific abnormal GI tract codes. And that's R 93.3. If it's to the biliary system, it's R 93.2. So specify the location of the abnormality documentation of esophageal varices in individuals with suspected portal hypertension or cirrhosis. So when Kristen was going through ICD-10 codes and she mentioned that the liver condition needs to be a primary diagnosis, it's true also for your indication for scoping to screen for varices. We don't really have an indication for screening for upper jaw endoscopy. All right. There's really no such thing as a screening EGD. So if you're screening for varices, it means that patient has a condition that you suspect varices may occur. And so cirrhosis, hepatic fibrosis, portal hypertension, you need to document that condition to assess acute injury after caustic ingestion, to identify upper jaw etiology of lower jaw symptoms like diarrhea. You know, we routinely don't see diarrhea as an indication for an EGD. So you have to explain why you think it's such in particular to evaluate persons with radiographic findings, suggestive alkalasia. So again, we're looking at an abnormal upper GI series in particular. So what's considered not medically necessary. Now this is actually Anthem's policy. So it's screening of any of the following, an asymptomatic upper GI tract of an average or skin individual. So why would you automatically do a screening EGD? Now it says follow-up screening for Barrett's after a prior EGD screening exam was negative for Barrett's esophagus. All right. Aerodigestive cancer, surveillance for any of the following healed benign disease. So esophagitis, gastric or duodenal ulcer. All right. So what they're saying is, and say you scoped a patient two weeks ago and there was a large gastric ulcer, and you are going to check now to see if there was healing, right? You're still going to use an ulcer code because that patient still has an active ulcer. As far as you know, this will be covered, but if you get in there and you find out the ulcer has pretty well resolved, it's completely healed over it's scarred in particular, it's the next EGD that will be the problem area. And that would be the can considered a personal history of an ulcer. All right. That is not covered, but if the patient does have a history of an ulcer and they also have upper GI symptoms associated with it, you're going to report the symptoms. All right. Surveillance for gastric atrophy, pernicious anemia, fundigland polyps, that's not considered medically necessary. Gastric intestinal metaplasia, also the surveillance for that is also not considered medically necessary. Now you notice that when we went over the new ICD-10 codes for this year, we had an abundance of codes specific to gastric intestinal metaplasia, site specific and those with dysplasia, high grade and low grade. And I know there's been some, let's put it this way, potential conflict over the lack of surveillance for those conditions. And I know that several providers, physicians, et cetera, have petitions. Some of the medical directors at some of the carriers, but we haven't seen any change in policy on this just yet. Previous gastric operations for benign disease surveillance from achalasia is not covered. An asymptomatic uncomplicated sliding hiatal hernia. That's never going to be your primary diagnosis, by the way. And I know a lot of times you find sliding hiatal hernias during an upper GI endoscopy. You would not report that as a primary. You would put down the symptom. You would put down any other condition. If you want to put that down as a finding, you can, but don't put it as primary. Uncomplicated duodenal ulcer. That's responded to therapy. Again, it's not subject for surveillance issues. Prior to bariatric or non-gastroesophageal surgery in asymptomatic individuals. And again, we're back to the asymptomatic. If the patient has symptoms, list them. All right. But often you guys may be asked to scope a patient prior to any type of bariatric procedure. Also could be possible prior to transplant situations to make sure that there's no cancer lurking somewhere. But again, if patient's asymptomatic, it's considered a screening and it's not covered. So that means an ABN farm, that patient be aware that this may not be considered a covered situation. Metastatic adenocarcinoma of unknown primary when the results will not alter management. Document that you're in a will alter management because the oncologist is trying to rule out the source, you know? So they're wanting you to scope this patient. Obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude Barrett's esophagus. Might as well also state, you know, obtaining tissue samples from endoscopically normal tissue period in the absence of symptoms. So again, list your symptoms to support medical necessity and any symptom that can be considered functional in origin is not considered covered as a reason for diagnostic EGD. So if you wanted to check out to see if your payer has policy, you want to search by upper gastrointestinal endoscopy or upper GI endoscopy. If you search by EGD, you will not usually find the policy. So medical necessity for infusion services. Now, I know I talked a little bit about this before, but I can't, I really can't stress this enough because this is one of the common questions that we get. You know, why are the payers, you know, not paying timely on these? Well, the answer to that question is because these are a lot high dollar dollar services. So do you have documentation in the medical record to support the reason for the initiation or change of any biologic agent? You know, so we're talking about medical necessity here. Be specific as to lab studies, patients, signs, and symptoms. Again, list and make sure that the specific IBD condition is documented. List all associated complications. Now, one of the things that Nova test, when they did a review of this one practices, they wanted to actually see the patient's TB tests and vaccination status. So was there due diligence before you even started infusions? Do you have a current medication order again, back to this to include drug dosage and frequency. And again, any delay in payment on these services causes an increased financial burden. And this is about three years ago, between July and August, there was a glitch from United on paying for infusion services. And I mean, practices, we're talking about hundreds of thousands of dollars backlog, you know, so make sure that the documentation is there. Make sure that your nurses know that they have to have the current order. They have to have the specific condition. the name of the supervising provider has to be documented, et cetera. All of that needs to be in the medical record. Medical necessity for evaluation and management services. So the level of visits should be based upon decision-making or time. I think you all know that. The benchmarking statistics. So what Kristen just showed you a little bit ago, you need to run the reports monthly and then yearly by provider. And if you get a letter from a payer that says, oh, you know, you bill 99214 more than your peers. All right. They're looking to see after that letter, did you take it seriously? Did you really look to make sure that, you know, you read the letter? Because most of the time it says, we recommend that you look at your claims and refund any overpayments or make sure that you're coding accurately to the type of decision-making that you provided for the patient. So what do you think they're looking for after that letter? They're seeing if there's any change in your bell curve. Right? Did it go down? Did it go up? Did it stay the same? So if it goes down, they're like, oh, you did over-document or you did over-code a little bit. So maybe we need to sample you. All right. If it stays the same, they go, oh, you didn't take us seriously. So maybe we need to sample you. And if it goes up, it's like, uh-oh, we should never have sent them that letter. They've been under-coding all along. All right. So again, they send you statistics and they take it from national statistics. That doesn't mean what's submitted is accurate. That just means it's a basis. It's just, you know, it's like, oh, well these, you know, they didn't know if they've actually submitted the claims accurately. It's just a model to go by. So again, they routinely sample these high-dollar codes and it means that you should also sample these as well. So recommendation is to review all high-level visits prior to claim submission. And then of course, educate providers on any like errors in particular. And I know most of you are like thinking like, we don't have the staff to do it. And then some of you go, well, we do. You know, so some practices do look at everything that goes out before and some don't. But if you don't, you should routinely sample those level five services. All right. So diagnosis codes also can trigger a pay down on the level of service. So say an established patient visit with a diagnosis of GERD is submitted with level 99214. No other diagnoses were addressed and not submitted and not linked on the claim. All right. We do know from a one payer in particular, Anthem in the state of Indiana, they have a list of ICD-10 codes per levels of service. So if you submit this diagnosis code and you bill a level four, they say it doesn't meet the requirements for it and they'll down code it to say level three and you have to respond to it. So if you can prove otherwise, you're going to have to submit your claims. Well, they had such a backlog in October 15th of this year, they stopped doing it because they were still, the one practice that we deal with, there were 700 claims they had to dispute and they were only into 200 of them beforehand. So again, they were looking at this just by the diagnosis codes submitted on the claim. All right. So 99214, when Kristen went over this before, two or more chronic conditions or one chronic condition is flared are still not, but still not a goal. So the patient still has symptoms. So like when she said that the heartburn, the epigastric pain, the GERD, is a symptomatic GERD patient that would support level four. All right, if you have two chronic problems that are under control, you would submit both those diagnosis codes. So again, the diagnosis codes that you submit on the claim or don't submit on the claim can definitely affect your payments and whether or not you're going to get an audit. Providers should also pay close attention to the core elements of E&M service. So again, the HPI, the medical decision-making, those are your core elements. And then compare the diagnosis code submitted against the chief complaint and the impression in plan of care. And make sure that the provider uses medical decision-making to score any established patient visit. But remember, medical decision-making doesn't support the level, then you use time. All right. Now, imagine that the provider doesn't fully document everything done in that encounter. We've seen that so much, right? And sometimes we can't even figure out why the patient has even come in. It's a very scant note. So focus on your impression and plan and include every problem addressed with a plan to match. And again, avoid that pre-populated problem list. Only list the conditions that you address and influence your management for that day. The principles of medical record documentation. All right. So number one, the medical record should be complete and legible. I think most of the time now we see an EHR, but you know what? We do see handwritten notes on anesthesia. We see handwritten notes on infusion services, but again, they should be complete and legible. Some are not. The documentation of each patient encounter should include the reason for the encounter, the relative history and physical exam, and the assessment, the impression, the plan of care, and the date and legible identity of the observer. Remember, sign the note. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. All right. So that means in the impression and plan, in the HPI, you should be able to figure out why you're ordering a test. Past and present diagnoses should be accessible to the treating and or consulting physician. Appropriate health risk factors should be identified. The patient's progress, response to, and changes in treatment and revision of diagnoses should be documented. And the CPT and ICD-10 codes reported on the health insurance claim form should be supported by the documentation on the medical record. All right. This is actually, you'll find this in the CMS 1995 documentation guidelines. That is under the general principles of medical record documentation. They haven't changed. So the provider's role of the assessment and plan. Your assessment of the patient should be clear and include any detail in the diagnosis that was relayed in the history. Do not quote from the problem list. When comorbidities and risk factors play a role in the provider's medical decision-making, clearly state those risk factors and why in the assessment and plan of care. I think Kristen, when she was going over the risk factors, especially for endoscopies, make sure and bring that into your thought process. The plan of care should show evaluation and management and treatment of every condition that relates to an ICD-10 code that you are submitting on the charge. All right. So not only should providers show evaluation and treatment for all conditions, don't sell yourself short on some of these things. You know, oftentimes your conditions may be addressed, but they don't make it into the impression and plan. It is acceptable to include history of conditions if it only affects the current treatment. So sometimes there's a history of colontalics in the impression and plan, and then the physician orders a surveillance colonoscopy. That actually is okay. But remember that when you put history of, the patient no longer has that condition. Now a search, and this is one of the problem areas with the electronic medical record and searching for ICD-10 codes. We see sometimes that the actual cancer codes and benign neoplasm codes are actually submitted on a claim, but the patient no longer has cancer and they no longer have an actual agnoma because it was removed. But it's how you search. If you search history of by the EHR systems, most of the time it leads you back to a cancer code or a neoplasm code. In order to get to the personal history codes, which means it's no longer there, you have to search by personal history of. All right, endoscopy tips. All right, but before we get to that, I have another question for you. If medical necessity is not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. Is that true or is that false? 47% true and 53% false. That actually is true. All right, so if the medical necessity is not documented, as long as you can figure out why it is ordered somewhere in the HPI, all right, it's okay. But you know what? Best practice is to be crystal clear in the impression and plan. That was kind of a tricky one. You're good at that. Good, you gotta keep them awake. All right, so endoscopic billing tips. You cannot bill for multiple polyps and lesions removed by the same technique. And that's a question that I've been kind of answering. So if you did 12 polyps removed by snare in multiple areas, you can only bill it for the snare technique one time. Modifier 22 for unusual procedures can only be billed if documentation supports tremendous complexity and time spent to complete procedure. All right, so just because you removed 12 polyps doesn't automatically mean that you couldn't add a 22 modifier to your claim. Can bill for each technique used to treat different lesions. So a different lesion, a different technique. All right, so snaring the sigmoid biopsy of the transverse, you would use a 59 or XS modifier to the bundle code. I'm gonna recommend XS for the payers that accept the X modifiers, and most of them out there do with the exception of Medicaid and again, back to some of the regional payers. It doesn't seem like the payers have their edits set up as much with modifier XS as they do with modifier 59. So if you're unsure if these are bundled, et cetera, the billing staff should utilize CCI edits or our claim scrubbing software. So EGD with biopsy is bundled into any esophageal dilation code unless the biopsy is outside of the area of dilation. And providers need to specify the exact location that was biopsied. So if a linear dilation was done, the biopsy has to be a separate area of the esophagus. If savory dilation is done, which often encompasses most of the esophageal area, then the biopsy would be done in the stomach and or the small intestine. Biopsy is also bundled into several ERCP codes. And this is all since 2018, such as sphincterotomy, stem placement, and dilation. So again, be specific as to the location. Make sure to document why the biopsy was done. So specify what the differential diagnoses might be. Double balloon enteroscopy. For the oral approach, you're going to use the 44360 series. If the ileum is not visualized, you're going to use the 44376 if the ileum is visualized. And by anal approach, you're going to use colonoscopy if a colonoscopy was actually done in addition to an unlisted procedure of the small intestine. The term endoscopic mucosal resection should be used when billing for an EMR. Kristen went over that in detail earlier. We know that the claim for the EMR is often pended by the payer, just to verify that the documentation of EMR is there. Make sure that your indications are clear. Do not use the indication of upper GI symptoms. Be specific as to the type of symptoms. So for our physicians that are listening in today, if you bring anything back, bring back symptoms, symptoms, symptoms, documented on your upper GI endoscopy codes, and as well as your colonoscopy codes as well. Incidental dilation, the dragging of the balloon is considered part of any RCP done to remove stones, to slate, sludge, and debris. So in order to bill for the dilation separate, which is bundled into any type of removal of debris and stones, you have to make sure to document the location of the strictured and narrow area and the well at the method used to dilate. Make sure to document the location of each stent placed during ERCP. Now we were talking about the code for upper GI endoscopy with stent placement of 43260, which has an added of one. This one, 43274 or 43276, if there's an exchange of a stent, you can actually bill more than one stent in the biliary tract. Now there is an allowment of two on this one and by most payers, but again, our doctors have to document the location of each one. Document the cholangioscopy, our spyglass was used during the procedure. This is not cholangiography, which is the injection of contrast, which is part of every ERCP code. This is, it's like a scope within a scope. So the spyglass was used during the procedure. It's an add-on code to any other ERCP code. The interpretation of biliary and or pancreatic duct images during ERCP are billable. And those codes are 74328 to 74330, provided that the endoscopist personally interpreted the images. There's a static image kept on file and there's no conflict with the radiologist also billing for the interpretation. And then you need to say, I did personally interpreted the bile duct images. That statement or the pancreatic duct or the biliary and pancreatic duct images, that statement has to be in your report. When banding or treating hemorrhoids, a endoscopy is included in the procedure and it is not separately billable and no modifier will bypass the coding edit. Controller prevention of bleeding is bundled into every endoscopic procedure and cannot be billed unless it's a separate site or a separate lesion. You always would use the excess modifier added to the control bleeding code. And Kristen already talked about submitting an unlisted code and the type of cover letter that you need for that. So the take home from this, always list symptoms which require diagnostic evaluation and differential diagnoses. Remember your pre-authorization staff has to rely on the specificity of your documentation. So any delay in pre-authorization also impacts your patient care. Make sure that all pertinent comorbidities are listed. Make sure that specific indications are listed on the endoscopy procedure. Any lack of specificity or vagueness directly impacts your reimbursement and it can lead to delayed payments and possible recoupments. Make sure that all documentation is completed and signed in a timely fashion. Preferably within 72 hours, if at all possible. Keep up to date on all payer policies and share with our providers and pre-authorization and billing and coding staff. So local coverage determinations that come out always have medical necessity issues. Make sure and share that with everybody. All right. If it isn't documented, it isn't and it wasn't done. So thanks everybody.

medical necessity

reimbursement

audits

documentation

EGD policies

infusion services

endoscopic billing