After EGD, when gastric biopsy is positive for H. pylori and you send antibiotic when relaying biopsy results, as we didn't see them in clinic or created a visit, is there any way to get paid for H. pylori treatment? Well, technically it's just like giving your patient results. It's considered part of the care, post-op treatment in particular, and it's not usually billable. It's not considered a billable service. It's the same thing for telling a patient that their polyp is benign and we're going to have them come in and recall in five years. One of the things that some of the payers are looking at specifically with telephone calls is, is this a patient-initiated visit or is this something that now, because you get paid for telephone calls, are you just billing a telephone call just to tell the patient results? So again, if this is just what you would normally do to tell the patient results, it would not be considered billable. There are times it turns into something more complicated. You send in antibiotics and you then hear back that what you sent in isn't being covered. You have to then have some other session with the patient to re-explain what you're going to have to get them instead and go through new prescriptions and set up for the follow-up testing that you explained to them needs to be done a month or two after treatment's done, all of that. It may wind up qualifying as, in effect, a separate encounter, but you have to be careful about the amount of work and when that occurs and how much back and forth with patient, pharmacy, et cetera, occurs, lab orders being sent in, all that. That's the field of the documentation. Okay. Thank you for that. Kathy, you indicated you wanted to do this one as well. Is the payment the same for ultrasound, infusion, fiber scan, and other procedure locations and why? I think I need to have a little bit more information on this one. So the ultrasound U.S. diagraphy codes are different than the fiber scan codes. I'm not exactly sure about, and I think I was doing a little research on this and there is something for saline infusion, ultrasound, U.S. diagraphy. Dr. Lindenberg, do you have a little bit more information on that, by any chance? I don't think it's something that we're talking about liver elastography for in that case. But fiber scan usually is going to be a globally built code. It won't be something where your hospital outpatient has a device and you do the reading. So you're usually not splitting it into two codes, a technical and a professional fee. Ultrasound, generally it's going to be performed by an ultrasound trained tech who may be part of your practice, but usually going to be read by an outside radiologist. So in that case, it's going to be separately built with a technical and a professional modifier. If you're doing the service in your practice, otherwise you're sending the patient to radiology. So it's unusual. Now, there are a few practices who have their own full-time radiologists who are part of the practice and they own a CAT scan machine and they'll do the global service as part of the group, but that's very uncommon. So it really depends on the specific test you're talking about. Most manometry services are done, hospital outpatient for the technical part and the professional reads it later, and generally the same with Bravo. Some offices, some practices have the Bravo equipment and do the global billing for them. So it depends who does what and where. Okay, thank you. All right. So we have some questions that have come in. It looks like it's from the same person, but it's about 99211. So I'm going to go ahead and ask both. Can a 99211 be billed with a 91065 HBT if the medical assistant is performing the service? They go on to say height, weight, blood pressure obtained with results given to patients, plus and medication filled if needed. They then ask also, can a 99211 be billed with a 91200 Fibra scan performed by a certified technician qualified, who is qualified to perform this? Any specific documentation required for billing the 99211? That was a lot. I'm going to say no. No. If the patient's already scheduled to come in for a Fibra scan, that encompasses the normal routine stuff that the medical assistants are doing before, after, whatever that Fibra scan. That's all included to me in the RV use for that reimbursement. I think that 99211 is more for, it may be a patient that's coming in and you're giving them some medication teaching, you're doing some blood pressure, checking their vitals, things like that. But it's not associated with something else already they're on the schedule for, if that makes sense. Yeah. Just because the patient walks in the door, you cannot bill a nurse visit. That's kind of one of the areas, 99211 does get looked at by payers and primary care providers have gotten nailed on this one big time, that they billed a 99211 just for somebody coming in for a blood draw. All right. You can't do that. There has to be, remember, this is going to be a Mycomodifier 25 situation. You're already performing another service that day. So this is besides saying, how are you doing? There's got to be a medical reason why you're billing that visit, not just to check on the patient prior to any type of diagnostic testing. Yeah. It's not done much in a GI practice, typically. It used to be common in primary care when warfarin was the main anticoagulant. Patients would come in to get a proton drawn, they'd be asked a series of questions related to adhering to their diet, their medication, their side effects, and so forth. That's kind of gone away with the anticoagulants used mostly nowadays. So in a GI practice, it's unusual. But for FibroScan, for breath testing, the global service or the part of it you're doing encompasses the interaction with your staff. All right. And our next question is, can you please express the importance to providers regarding documentation of biopsy taken from, and they have this in all caps, entire colon, is not enough and to be specific. So Kristen, you want to have a run at this first? Yeah. I was just going to make a couple comments on this one. So usually when I see a provider document that they're taking multiple biopsies within the entire colon, they're probably, you know, the patient probably has ulcerative colitis, things like that. And they're doing biopsies in all the different areas to see if there's disease there. If there's, you know, flare or whatever, inflammation. So definitely need to be specific as to where your biopsies are done. The method and one big pet peeve of mine is biopsies for histology. What does that mean? We understand you're taking biopsies for histology, but what are you ruling out? And I think especially if it's like a symptomatic patient and you're biopsying for microscopic colitis, usually you say that biopsies to rule out microscopic colitis or celiac disease or Barrett's, anything. There's a lot of things that you guys rule and what to rule. The pathologist wants to rule out based upon the symptoms. So you have to, you're telling a story. You have to support medical necessity for the biopsies that you take. Any other comments on that one guys? With the word in cold biopsy forceps. Yes. That's a big one of the instrument used and EHRs are very good about inserting that template language when you click on biopsy, it'll put that in, others you have to put it in yourself. And if you're using some special, you know, large, large volume jumbo forcep or something different, again, you should include that just so it's very specific, but yes, reference to why you're taking it, if it's not obvious, you know, if you're describing an ulcer biopsies are taken, you know, it's kind of understood why you're taking them, but if you're doing random biopsies of the antrum, because you suspect H. pylori, because patient has dyspepsia that that needs to be stated or the esophagus for eosinophilic esophagitis. So our next question is, is IBD cancer screening considered colon screening of established IBD evaluation? All right. Okay, so it depends on what you're going to do, honestly. If you go by the Affordable Care Act, it's not screening. It's an established medical condition, they consider that a diagnostic because it's usually somebody that's going to be scoped more than once every 10 years. Now Medicare does have IBD codes as indications for GEO 105, all right, but that means that you're not intending to do biopsies at that point, all right, and most of the time there's planned biopsies, but again, we do have some different guidelines, the state of Oregon has some different policies within their state that allows for patients with IBD to have actually screening, all right, as long as they're asymptomatic. So you know, there's different criteria, different payers have different guidelines in particular, but it is usually considered a medical condition. Right. And there may be, conversely, may have a patient who has ulcerative proctitis, you know, very limited disease, no higher risk of cancer, and the condition is quiet, and you're really doing the screening on them. Yeah. Then I wouldn't be mentioning the ulcerative proctitis and the diagnosis codes for the procedure. It might be in your note, you know, patient's stable with ulcerative proctitis, but is now due for screening colonoscopy. So you know, in your note, you have both things described, in your procedure, you're using the screening codes, because that's what it is. Okay. But again, you need to be clear on that. So as long as your documentation supports that. Okay, there's one question at the top, and I'm not exactly sure if that's a coding question in particular, but it's been out there for a little bit. Yeah. I would, if Kathy, if you want to take this one, the words are a little bit broken up, but I think the spirit of it is, is they have a contract employee that might not be doing what the contract employee needs to be doing. But it says internist contracting to do something. Office visit H&P maybe? Office visit H&P, excellent, excellent. And follow up hourly, and doing his taxes and no benefit, is he considered an external provider? So is the gist of this that they've got a contracting internist, and would that person be considered an external provider? I mean, I guess regardless of, could we address this regardless of whether or not they're doing, they're performing well or not? Is that an external provider? It's like a locum situation. You know, that's kind of, it's like, I'm not exactly sure, you know, whether or not he's a credential provider, even though he might just not be full-time. I'm not sure. Okay. So, Dr. Almodany, if you want to kind of raise your hand and open your phone line to give us a little more context for this, well, well, that was fast. I'm just going to open your phone line there, and I think you're muted. So there you go. Go ahead, Dr. Almodany. Why don't you explain your question a little better? Yes. The question is about somebody who you made a contract with him to come and do your history and physical or consult, and he's not gastroenterologist, he's a board-certified internist, and he's delivering the care for you on hourly basis. Is he considered external contractor, or is he part of the practice? Who's doing the billing under whose, you know, how does this go out? Is it coming under your practice, NPI, with him as the rendering provider, or is he doing his own billing? The billing is done in the same place where he's contracting himself with that place. I mean, it's in the office or in the center, the endoscopy center. In the endoscopy center? No. If you have, the physician is doing most, the GI physician, he does most of the endoscopy work, and this man comes to do the history and physical, the consultation, the follow-up office visit, and he comes on a certain time to do that, so he's helping, but the billing, as you're asking, it's done in the same office. Well, again, it kind of comes back to whose NPI is the bill going out under, yours or his? No. He's an external person, and when you review the document, it's an external document, but if it's within the practice and he's just doing contracted work for you, then it's an internal document, and you're just paying him or whatever. He's like CRNA, who's contracting for hours, and he had the NPI obtained for that particular facility, but we bill for him. Okay, then it's basically part of your practice. Right. You mentioned something, though, about what sounded like pre-procedure histories and physicals. Be careful about that. Those are part of the endoscopy. They're not separate. No, no, no. It is consultation. He's doing consultation and follow-up. He's not interfering with the endoscopy or prior endoscopy evaluation. He is just internist, non-gastroenterologist, but oriented about gastroenterology practice, so I'm trying to compare him with either the pathologist who does work for the biopsies, et cetera, and the CRNA who does that as well, and both of them are contracting physician or a nurse. Okay, I view that as part of your practice. I don't know. Kathy? If it's going on under your NPI number, then they're considered part of your practice. They would be considered internal. Okay. All right, thank you, and so this is a question. It's a follow-up to a question that was answered in writing earlier, so I'm just going to go ahead and re-ask the question. I think, Kristen, you may have been the one who responded to this, and I'll do this with the follow-up. So the question that was posed was, with the EUS, with EGD, 43259, only documentation is on inserting the EUS scope and only describes endosonographic findings and nothing else. Should we be asking for the endoscopic findings, or is just the endosonographic documentation enough to build the 43259? And the follow-up this person wanted to know is, should they be asking about the EGD findings if there were EGD findings? So could you just maybe restate what your written response was, Kristen, if it was you or I'm not sure if it was you. Yeah, and I guess maybe I need Kathy and Dr. Lindenberg's opinion on this, but typically, I mean, EGD is part of EUS, and usually there are two different findings. I guess I've never seen an EUS without an EGD or endoscopic finding along with it. Most of the time they do it standard scope first, because oftentimes, you know, the EUS is not done usually by the provider that did a previous EGD. So oftentimes, they'll do an EGD first, look into the small intestine, see if there are any issues, and then they'll proceed with the EUS. So that's why sometimes we see the EGD biopsies done to say erythematous lesions in the stomach or something in the esophagus, and then those are definitely billable services. All right, and I don't know as far as the ultrasound findings for 4.3259. Remember that the guidelines for 4.3259 state that this is a complete EUS, which means that you've examined the esophagus, stomach, small intestine, plus any adjacent areas with the use of ultrasound, or echoendoscopy, or however you want to do. You do have to make sure that you do make a statement that those were viewed per EUS. All right, and go ahead. I think their biggest question was just that can they still bill, can they go ahead and bill 4.3259 if they make no mention of endoscopic findings? Yeah, I mean they did it. They did it. Yeah, but if you do a standard EGD, I mean if you do a standard scope as well, you definitely should mention that. Yeah, yeah, somewhat dependent on the type of scope used. A radial scope, you get much more visibility. A linear array scope is you're looking more sideways, so there may be much more limited views, but I mean usually some mention of whether any pathology was visible is still done, but you don't have to have any certain amount of endoscopic findings to qualify for billing the EUS. Yeah, that's where I was going with it, but I just wanted to make sure of it. Okay, we have one question in the queue, folks, so unless you're slowing down, everybody, come on, let's bring them. Oh, there we go. I knew we'd get them back in, and you can always raise hands too, so we can't open phone lines. I think we answered this earlier, a similar question earlier, but I'll just ask it again. Any good book or resource for recent graduates to master the billing and coding? So, Kristen, would you like to take a run at that? I can't master billing and coding. I'm just kidding. It's such a, no. We've got the Coding Primer available through ASG, and that's pretty well the coding and reimbursement Bible for GI. There's webinar series. There's, I would say, the Coding Primer. Okay, and that's available in our store. And we are going to update that with the E&M changes, I believe. Wonderful, wonderful. And the next release. To get the current version of the Primer, you should really read through the revisions of the E&M guidelines, but they're available easily online from AMA. If you just Google E&M guideline revisions AMA, you'll probably come right to it. So, it's easy to find. It's a bunch of pages, 20, 30 pages of fine print, but it's important to understand those guidelines because it really is all behind what's changed in E&M billing and what's going to change for the other codes pretty soon. And as soon as you think you got it mastered, they change the rules. So, there you go. You know, before, and we still have some questions coming in, I do want to quickly point out to folks as we start to wrap up the day that there is a member benefit. So, ASG members do get the wonderful benefit of being able to submit their coding questions and get them answered for free via email throughout the year by Kathy and Kristen. So, if you are not current with your dues, we know that the dues invoices are out, or we do have other categories like associate and affiliate memberships, you can send an email to info at ASG.org if you would like to get some information on membership, because I think that is a pretty fantastic benefit having these two at your fingertips, so to speak, at your keyboard. You can send them your billing questions throughout the year. Our next question is, are there any modifiers or changes to billing when performing procedures with a CAP? For the CAP, no. No, but CAP is sort of some of the equipment that if you're doing EMR, there is a reference to that as kind of a special tool. So, it should be mentioned if you're doing EMR that a CAP-fitted scope was utilized. But if you're doing it just as part of diagnostic endoscopy to try to make it more effective at finding polyps, no special coding, which is a little problematic because the device costs, I don't know, about 20 bucks. And unless you turn a procedure with no polyps into one that has polyps that you find because of the CAP, you don't get those costs reimbursed in an ASC setting. Okay. Are there any modifiers to use when using an EGD for a patient with familial polyposis syndrome and you use a separate scope, a side viewer specifically, to evaluate the ampulla in addition to the gastroscope? That's really more of a clinical question. I guess many people will start out with the forward-viewing scope. And if they get a really good view of the ampullary area, that may suffice. If they have access to a side-viewing scope, depending where they're scoping, they may swap it out if they're not getting an adequate view. But it's still a diagnostic endoscopy or whatever it is endoscopy you do. You're not doing some extra procedure, extra code. There is not a very good set of ICD-10 codes for familial polyposis kinds of problems for which you do upper endoscopy, unfortunately. So that's somewhat of a problem. And I don't know if Kathy or Kristen have some advice about how to build under that circumstance for a negative upper endoscopy. If you don't biopsy or remove some specific region, how would you build that? That's an ABN. That's an ABN, yeah. If you don't find anything, especially, yeah, that's an ABN. You know, for the polyposis code is D12.6, you know. And even if you would say family history or even personal history of colon polyps doesn't give you an indication to do an upper. You know, that's not an approved indication. So in the absence of symptoms, in the absence of findings, there's a good possibility you're not going to be paid for this. You know, so definitely recommend an ABN. Make sure the patient is aware. Of course, they're not going to really be happy, you know. Well, why are you doing it if it's not covered? One of these situations. But this until, you know, and I know years ago they were talking about getting screening approved, a screening EGD approved, but it doesn't sound like we're any anywhere close to that. Is that correct? Correct. So folks, we had a question about, could you just maybe say what an ABN is? An ABN, Advanced Beneficiary Notice. All right. It's, you can just google it, ABN farms, Medicare ABN farms. It'll get you a link right into it. You can download the forms. The last revision was for August 31st of 2020. It has complete instructions on how to fill it out. They're available in English or Spanish. The patient has to be informed of why the procedure may not be covered, what their approximate cost would be. The reason, again, the reason why it may not be covered has to be detailed. And then the patient has to mark box A, B, or C saying if they want the procedure, if they don't want the procedure, et cetera. It has to be dated and signed, and it has to be given to the patient far enough in advance in order for them to make an informed consent, informed decision. So usually at the time of scheduling. So in this situation, you know, it's like Medicare doesn't have this as an approved indication for upper GI endoscopy. If you know your payer, now I can't say Medicare doesn't because there are some Medicare payers that don't have policies on upper GI endoscopy, right? And if they have a policy, I know it's not on their policy list, but the assumption is it's not considered a screening EGD is really not covered by the majority of payers. So it's really good advice if you want to get paid for this, or at least get potential payment from the patient, that the patient be informed at the time. And even though the ABN is published by CMS, you can use it for commercial payments too. It's just a kind of a handy form and process to follow to try to inform patients and get their agreement to be responsible if it winds up not covered. Something that's never covered by Medicare at all doesn't necessarily need that kind of a form, but it's still prudent to get some kind of waiver, maybe not something that complex. Cause if it's never covered by CMS, never covered by Medicare, you don't need the ABN for things that sometimes are covered, sometimes not depending. Okay. Our next question is, can you bill EGD with control of bleeding for non-bleeding AVM in duodenum, which was cauterized to prevent bleeding in patient with anemia? Well, don't all jump on this one. All right. So, okay. So control of bleeding can be utilized for something that looks like it has recently bled. There's a visible vessel, has a clot, is oozing, has actively bled in particular. All right. And the diagnosis codes that you assign for control of bleeding are codes that have with bleeding attached. So angio-dysplasia with bleeding, duoploies, ulcers with bleeding, et cetera. Now, if it looks like it could be the source, but there's no evidence it has, and you're using an APC to cauterize that lesion, you can bill it as an ablation. All right. So one or the other is billable. And there is a few RVU value differences between the two, depending on which area that you look at the lower, I think on the upper control of bleeding pays higher than the ablation on the lower, it's the opposite, but it's not that much difference in between. But again, you know, there's a question, if you're unsure that your doctor, you know, if it's actively bleeding or not, you know, ask your doctor to confirm this a little bit more. Just so visible, like I said, visible vessel, looks like it recently has bled, source of bleeding, clot, oozing, et cetera. Any of those can signify a controlled bleed situation. All right. We have no questions currently in queue and no hands raised. So folks, if you have another question, please go ahead and enter it in the Q and A box or raise your hand. Do our panelists have any questions for each other at this point based on today? I think they've all been asked and answered. It sounds good. Maybe we've just come to our natural end. Do you want to take us to closing comments, Dr. Lindenberg? Sure. Thank you, Aiden. All right. Well, I appreciate all of you being so resilient and hanging in there. We have almost as many participants, right, as we did at the beginning. That's pretty impressive. Keep in mind that this virtual course we've sort of been forced into takes the place of what had been a day and a half to two day in-person course. So, you know, no wonder your head feels crowded and your bottoms feel sore. You know, not as much getting up, walking around time. And for that, we apologize. But I hope you found this an information-packed day and the resources that are right there now on GI Leap ready to download. We'll keep giving you and your team good information supplemented by primers or webinars, Kathy and Christian's courses, et cetera. So we've come to the end of the day. Pasadena is no longer shrouded in fog. We've now got, what, 82 degrees sunshine, beautiful blue skies. Lest you think you can move out here quickly, just check housing prices first. Thank you very much. I'll turn it back over to Aiden for concluding comments. So we got one question snuck in, so let me just ask it. Let's just ask it, but this will be the last one, folks. What modifier is best to use for same-day inpatient procedure patient with hematomatous? Do you do emergent EGD? Well, if you're just doing an emergent EGD, you just bill it as an EGD. Unless they're talking about consult, like consultation, and that leads to an emergent EGD, then you're going to build a consult with a 25 modifier. But again, provided your documentation just doesn't say the patient's bleeding when we're taking you to endo. Right. So you've got good documentation. Significantly separate. Yeah. Yep. All right. With that, we'll take our heads back to Pasadena and the beautiful setting Dr. Littenberg was giving us of sunny Southern California. And I would just like to congratulate all of you, both the faculty and attendees, for a really wonderful course. We appreciate everyone's engagement. It was a really wonderful day. As a reminder, each of you will have ongoing access to the recordings from the course via GILeap, ASG's online learning management system, when they're available. And that's probably going to be sometime in December, maybe early January with the holidays. So we're going to email you when they're ready. So you'll be able to go back in and listen again to all the words of wisdom you've heard from these three fine people. The course evaluation is now available in GILeap. And once you complete it, you can download your certificate. If you need assistance logging into GILeap, please email practice management, and that's the two words practice and management squished together as one word, at asge.org. This concludes the ASGE 2022 Reimbursement and Coding Course, as well as our overall GO Practice Management Trifecta, a four-day arc of courses. We hope the information that you've gathered over these days is useful to you and your practice. Thank you, Aiden. Thank you. Thank you.

billing and coding

gastroenterology

H. pylori treatment

EGD

biopsy findings

colon evaluation

control of bleeding