2023 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2022-Best Practices in Coding for Ancillary Services Anesthesia Pathology Other Svcs

Pdf Summary

The presentation titled "Best Practices in Coding for Ancillary Services: Anesthesia, Pathology, and Other Services" covered various documentation and coding guidelines for different ancillary services, including diagnostic studies, infusion services, pathology services, anesthesia services, and nutrition services.<br /><br />For diagnostic studies, the presenter emphasized the importance of documenting essential information such as facility name, patient details, referring and ordering providers, dates of tests, medications administered, findings, interpretation, and signatures of interpreting physicians.<br /><br />Regarding infusion services, key documentation requirements included facility name, date of service, patient information, diagnosis, ordering and supervising physicians, medication details, dosage, total units given, start and stop times, rate of administration, and signatures of clinical staff and supervising provider.<br /><br />Pathology services required documentation of facility name, patient details, dates of specimen collection, receipt, and processing, ordering and referring physicians, clinical history, indications for stains, microscopic and gross descriptions, size and margins, number of units/specimens, diagnosis, and signatures of pathologists.<br /><br />Anesthesia documentation should include facility name, date of service, patient information, diagnosis, pre-anesthesia risk assessment, specific procedure performed, reason/findings, ASA class, type of anesthesia, position of the patient, start and end times, documentation of discontinuous time and relief by another provider, surgeon's request for post-procedure pain management, and legible signatures of the provider.<br /><br />Moderate sedation codes, G0500, 99151, 99152, and 99153, were discussed, and it was noted that G0500 is the specific code for sedation during GI procedures, while 99151 and 99152 were bundled into most GI endoscopic codes since July 2017. Documentation of time for moderate sedation should align with CPT and CMS guidelines.<br /><br />For nutrition services, the presenter mentioned the codes 97802, 97803, and 97804 for medical nutrition therapy, which can be billed by registered dietitians based on individual or group sessions and time documentation. Medicare only covers these services for diabetes and renal disease, while commercial insurance may have their own coverage policies.<br /><br />Overall, the presentation provided guidelines for appropriate documentation and coding for ancillary services, highlighting the importance of accurate and complete information to ensure proper reimbursement.

Asset Subtitle

Kathleen A. Mueller, RN, CPC, QMC, QGMC, CCS-P, ICD-10 Proficient

Keywords

Best Practices in Coding for Ancillary Services

Anesthesia

Pathology

Documentation guidelines

Coding guidelines

Diagnostic studies

Infusion services

Pathology services

Anesthesia services

Nutrition services