We are going to go ahead and go into that Q&A session. We have two questions that came in that seem similar to me, so I'm going to ask them both. So give me a second here, Kathy, and it's making that distinction, I think, between a screening colonoscopy and surveillance and diagnostic. So the first is asking to clarify if they can use PT modifier if what would have been a G0105 if negative turns into a therapeutic colon, and they're saying specifically for Medicare. Now let me read the other one, which I think is similar, but you'll tell me if it's not. You mentioned that a patient may be eligible for screening benefits despite a positive history or symptom as long as the provider indicates in the office note that the history or symptoms does not require an endoscopic exam. I always thought that any symptom or history of disease automatically disqualifies the patient for screening benefit. Can you clarify, on the procedure note, would the provider have to list screening and no reference to the patient's preexisting condition or symptom? Okay, well, they're a little bit different, but I'll do the first one on the PT modifier. Yes, that would be appropriate if you started out as G0105 or G0121 and you ended up doing a snare or a biopsy in particular, that we would use the PT modifier on the snare and that states it started out as screening. And then we would use the primary diagnosis, and this, again, this is payer-specific, and I know, I think, Dr. Littenberg, you were asking the question on this, and since you're under Noridian, all right, your primary diagnosis is going to be the finding. All right, so we would put the PT modifier on your snare. All right, so anyhow, and that waives the patient's deductible, but they're still going to be responsible for the 20% that Medicare does not pay. Now, as for the other one, the other question was, if the patient has a symptom, but you state that that is not the reason for the procedure, that it doesn't require endoscopic evaluation, that's appropriate. I mean, if you're addressing the symptom and you're saying that it doesn't require any type of endoscopic evaluation, then technically, that's not an indication. Your indication would be screening. And I would not be putting that as screening an incidental something next to it. You know, if you've already defined that that's not your indication, I'd leave it off. Okay. Our next question is, what are the instances you can use modifier 53? If you abort colonoscopy because of poor prep, what is accurate code to you? What is the accurate code to use? Well, you're going to use the colonoscopy code. You're going to use the 53 modifier, and I had in a couple of slides the diagnosis code that you would still use the intended procedure, the intended reason for the procedure, but then there is that code for the poor prep, Z53.8, which is, you know, procedure discontinued because of patient's condition. Okay. Next question. Oh, sorry. Did you have more to say? No, that's okay. And just be aware that any time you put a 53 on it, you're not going to automatically get paid. Your EOB will come back, and it's going to say further information is requested. So, you're still going to have to submit your note for review. Okay. Okay. Great. This person indicates they're one year out of training, and it's still difficult to understand all the modifiers. So, do you have a good resource for them to really dive in on those modifiers? Anything specific? Well, technically, the coding primer that you have published goes into a lot of detail on the modifiers. You know, we've also done some workshops with ASGE. We also do our own at Ask Miller, too. So, there's a lot of good information in the primer. I would recommend that if you haven't bought that yet. Okay. The ASGE coding primer that is available for purchase, excuse me, via GI Leap. So, you could purchase that today. Do we consider this case a screening colonoscopy? And here's the scenario. The patient is a 55-year-old, average risk. His previous scope at age 50 revealed no polyp, but the report recommended a repeat scope in five years due to a torturously and redundant colon. Okay. The problem with this is it's less than 10 years since the last one. All right. We don't know why he had the procedure five years ago, either. But it's going to depend on the payer on whether or not this is allowed, you know. And we could bill it as screening. This is actually where you want to ask a question, and you preauthorize and verify eligibility to make sure that this is covered. You know, and I'm sure a lot of you are thinking, well, what happens if they were under a different insurance company? And it's quite possible. A patient age 50 doesn't have the same insurance that they do at age 55. So, I would say if it says in your records that this patient is eligible for screening, you attempt to bill it as a G-code or with a 33 modifier and see what happens. All right. I'm not going to tell you it's going to get covered, but just make sure. You may want to get a waiver signed by the patient on these conditions because it may not get covered. That's right. You know, the ABN form, which we, you know, we have for Medicare. All right. But on 50 or 55-year-old patient, most likely this is not Medicare. Not necessarily, but you would have to utilize a different ABN form or a different waiver form for a commercial payer that you would do for Medicare. Just make sure that the patient is aware, so it may not be covered. And our next question is, would you still recommend use of 53 modifier if documentation states REACH-SECUM, due to poor prep, recommended repeat, but does not state a timeframe for repeat? Okay. Back to those three criteria that I mentioned, and again, it depends upon the payer. Medicare would cover this, all right? They have in their policy that they'll cover this. Now, as far as the commercial payers go, and I'm not saying you don't want to try it. You could try it, but they're going to review anything with a 53 anyway to determine whether or not it's covered. All right. The fact that they REACH-SECUM, all right, for the commercial payer means that it meets the requirements, but they also need to have when the patient needs to come back. And like I said earlier, the six to 12 months is kind of the window. There is no written policy on this, guys, but I can pretty well tell you from the auditors, when they look at that, if there's no timeframe that the patient has to come back, they think that the doctor is satisfied, and they don't want him to come back, and so therefore, it would maybe be considered complete. So anything less than a year usually will support the modifier 53. Next question is, can you discuss the change with United regarding positive FIT or Cologuard? Do you still bill it as a screening or positive occult stool? That's a good question. You know, Kristen, I don't know. You know, and you know what, I saw some of these questions come up is when Kristen was talking. So I got into United's policy just to do a double check on it. R19.5, which would be the code for positive Cologuard, is not a diagnosis code for screening. It is not approved for it. So I would just state that you would bill it as screening. All right. Your indication, I mean, I don't think I'd lie on there. Your indication would be a positive screening, positive stool in particular, but if you want to use R19.5 as a secondary, you could. But I would use E12.11 in the first position. Now, that's United only, and there is no guidelines, honestly. They don't give you the diagnosis codes when this policy came out. It's still not there. Anything to add, Kristen? No, that's, that was our question. You know, we saw that on United's policy. And we're like, well, what, how would you code that? You know, that was combining Kathy's first, and there is no guidance there. So screening, I would say screening, and then just positive. All these folks would love to be a fly on the wall on your chats, I'm sure, your coffee talks. Regarding screening colonoscopy, what if the workup from the nurse practitioner in visit prior to screening, and this is what the call to insurance and patient responsibility is based upon, then the actual, then, sorry, a little punctuation, then the actual documentation from the physician at time of procedure does not support screening. Patient has already been told covered under preventative. How do you handle that situation? Somebody did not communicate well. Or it just also depends upon the time between the patient was seen and scheduled, and sometimes they do develop symptoms during that time period as well. I think a lot of it depends upon what the doctor is going to do with that symptom. You know, if the patient displays a symptom, it's going to definitely impact what you do. So if you're going to have to do the biopsies because the patient told you about the symptom, then ultimately, the indication has changed. So, I mean, this kind of is left up to our doctors to determine whether or not this is really, let's put it this way, changes the true indication. That's a tough one. Well, we'll leave that there for now, and maybe that's something we'll revisit later if we have additional thoughts. Should incidental findings such as diverticulosis or hemorrhoids be documented on claim with a G0121? No. I'm going to tell you why. Your payer is looking for a reason to deny the screening benefit. All right. So if the doctor says, oh, it's kind of like, oh, by the way, the patient has some small diverticuli and a hemorrhoid. But if the patient wasn't symptomatic to start with, if you mention that on your claim, it could actually take away the patient's screening benefit. So, I mean, you're still going to keep it in your endoscopy report. Your doctor may have to refer back to it if the patient does present maybe with left or right quadrant pain in years to come. But it really should not go on your screening colonoscopy charge. Does Medicare now cover average risk screening at age 45? No. And I just looked at the policy. It was just revised in September. And it still has age 50. Dr. Lutenberg, do you have any? No, I don't have anything updated on that. I mean, if you do it for good reasons and you get denied, I mean, you can file an appeal and reference the Preventive Services Guidelines. It'll probably get covered, but it just gives you the extra steps of work. Do you still have to document endosynographical findings of each area to bill 43259? Kristen? Yes. Yeah, so the code description for 43259 is evaluation of all areas of the GI tract and adjacent structures. So if there's, if that verbiage is not in your report, we don't know that you actually evaluated everything. So you have to have that statement. And I think that was a clinical example that I put in there, and it was italicized for you. That's a statement you need to ensure that you're going to get payment on that full EUS. Okay, this, I'm not sure if we're going to need a little clarification from the person who submitted this. So let me just read it as submitted. If EUS is done and EGD different scope, I think, I don't know if they mean a scope or a different endoscopist, is it billing with modifier or only EUS? Is that question clear to you? Yeah. Okay, good. It depends. I mean, if it's just, if it's just the endoscope and then you do the EUS, you're only going to bill the EUS. If you do the EUS and you do a cold forceps biopsy separate, you can bill both. But the cold biopsy is going to take a modifier. So it depends on if you do another technique outside of the EUS. But if it's just your standard EGD with EUS, you're just going to bill the EUS. Okay, next question. When finding a large polyp during screening colonoscopy and removed by ink-based colloid solution like ORYS or EleVU, then hot snare resection and clip placement, can I quality, can I, I think it's, can I qualify for EMR? And then ORYS, EleVU is usually enough to delineate the lesion border. Does that make sense? Yeah, so that to me describes, I'm going to comment on a couple things on this one. The ORYS, the snare, the clips, that all describes EMR pretty well. And Dr. Lindenberg, you can comment too. But please make sure you, so the code, the auditors that are on the payer side are looking at the CPT code that you billed and the prescription, or the description of with endoscopic mucosal resection. So if all you have in your note is just the description of how you remove the polyp and that term EMR is not in that note, you may have to, you know, fight for that EMR. So make sure it does qualify, but just say I did the following EMR and this is what I did, and explain it. Now another thing, you said screening colonoscopy and you did an EMR during that screening, and that's okay, that's okay. But I will say this, a lot of the payers consider that EMR a second step procedure, meaning most of the time, typically on a screening, if you find a very, very large polyp, you're going to do an EMR later, you might tattoo, you might biopsy the site and bring them back, okay? So they may deny it for second step or want your documentation. So it's just another step in the process. But that doesn't mean they're not going to pay it, it's just they may pin it for review. I agree, yeah, there is some ambiguity between the two types of services, and there, you know, there are payment differences, though not huge on the professional side. And trying to clarify it in CPT, unfortunately, would lead to potential RUC revaluation of the base colonoscopy code, so we really haven't wanted to add more language or definitions, we handle it in CPT assistant articles, in our courses, in our primer. So, you know, if questions, you know, go look at some of those resources, but it is subtle. Okay, our next question, if some payers don't pay for saline left, can we appeal as other payers pay specified Medicare? Is that clear? I guess I'm not, I don't, okay, well, maybe, maybe, maybe this is it. Maybe is the referencing the saline lift polypectomy, and that's the case. So let's say, let's say they bill the snare and the lift together, and the payer pays the snare, but they don't pay the lift and they bundle it. Unfortunately, it's kind of hard to justify that's a separate lesion, it's really not a separate lesion. So I'm not sure that I would go through the steps to appeal that even though they're not on CCI edits. Any comments, Kathy? Well, I mean, you can always, you can always use CCI policy. I mean, because they're not bundled, but we're seeing, like I said, there are several payers, palmetto being one of them that states if it's a saline, if it's saline rise prior to a snare polypectomy, they don't cover it, but if it's actually tattooing, they will. So making sure that you describe fully what you do in there, and it's subject to appeal. You can definitely appeal it, but they're going to have to submit, you know, have to submit your note and stuff, and you have to have a basis. That's the thing, and it's like not necessarily pick and choose what you want to appeal, but you're losing a little bit of money off the top any time you're appealing and sending documentation and everything. So you want to appeal the, you know, you want to be kind of a, we always say the thorn in their side, you know. We don't want to just take the denial at face values, but also know that, you know. Well, you can kind of look at the upper GI procedures. You have the semipixel injection on the upper GI tract that is bundled with every endoscopic procedure with the exception of snare. So if you do an EGD with snare and you do a saline lift or whatever prior to that, say in the stomach, we're able to bill the 43251 for the snare with the 43236 for the semipixel injection. So that is justified on the upper GI side, so it could also be justified on the lower GI side as well. Okay. So we're going to do two more minutes just to try and at least give you guys a 15-minute lunch. We do have 16 questions in queue, so we're going to save those, anything we don't get to, to later in the day. We're just doing order received right now. So we're doing our best, but, you know, none of these answers are short, as you well know, and when you ask a question, you don't want a short answer. So we're doing our best, Sierre, folks, to get through everything, but you have a ton of great questions. Next question is, is full thickness endoscopic resection included with EMR codes or unlisted? Those are unlisted. Full thickness resection through an endoscopy does not have a CPT code. And EMR really by its nature is a mucosal process. Endoscopic submucosal dissection is a deeper service, but it's still not full thickness by design. It can turn into full thickness by accident, by complication, which you then may repair, but then you're submitting unlisted codes for the ESD part and for the repair part. So, you know, definitely not a, you know, conventional code. Okay. This will be our last question for this Q&A segment. If a necrosectomy is performed in which an axial stent is placed and then two stents are placed to keep the tract open, can the stents be coded separately? And they specifically say 48999 and 43266 times 3. Okay. So, if the stent was already in place, all right, which means there's already a cyst gastrostomy established, then you can build to replace the stent of 43266, but you can only build it once. When you look at the medical, let's put it this way, the exclusions as to how many can be billed per line item or per time, in particular, there is a limit of one on 43266, so you can only bill for one stent. You're already adding an unlisted code for 48999, all right? So, you can actually increase, you know, you could add the complexity of two additional stents in development of your code and your price for that 48999 as well. Originally, stent placement, you could bill more than once, but the APCs, the classifications of the procedures was changed a few years ago to a more comprehensive single APC where it includes whatever number of stents. So, the facility is really paid on a pretty high level knowing that sometimes one stent, sometimes multiple are there. Physicians really just get one payment. Well, thank you to our faculty. That was a wonderful session, and thank you to our audience for all these great questions. We are going to keep the 14 that we didn't get to for the end of the Q&A for the end of the day.

coding

billing

colonoscopies

PT modifier

Medicare

screening benefits