We're going to talk about the best practices for anesthesia, pathology, as well as some other services. So first of all, we're going to talk about diagnostic studies. Documentation requirements are very important for everything that we do. And I think everybody knows we have to have basic demographic information on the top of our records or the bottom, wherever that's contained. You know, patient's name, date of birth, medical record number. But for diagnostic studies, we have to make sure there's a referring provider and an ordering provider. And sometimes they're the same. The date the test started, the device was placed or swallowed, the date of download if separate from the date of insertion, the name of the facility, where the service is being provided at. The indication for the procedure study, very important, need to be specific as possible. Tristan mentioned that anemia unspecified, right? Sometimes I see that as a reason for capsule studies, and believe me, that's not covered. Description of findings, impression and recommendation, date and signature of the interpreting physician has to be on every diagnostic study. All right, so for documentation for requirements, first of all, what date of service should be assigned? So we're talking about specifically those that are broken down to professional and technical, and some of those are contained in the 51,000 section, the 70,000, the 80,000, and the 91,000 section of your CPT book. So for CMS, and this was last updated on February 1st of 2019, if you're billing as a global service with not a modifier because you own both components, then your date can either be the date of placement or swallow or the date of interpretation. If you're billing for interpretation only, that's modifier 26, the date of service is the date of interpretation. So therefore that date of interpretation has got to be on your study as well as your signature. For billing as technical only with this modifier TC, the date on the claim is the date of service. So on the commercial side, it can either be the date of service or the date of interpretation, all right? And so technically, guys, you need to check with each payer and create a spreadsheet for payer preferences as do they follow Medicare or do they have their own guidelines for this? So some of the GI-specific studies, manometry, pH and Bravo, impedance studies, capsule studies, smart pill, liver elastography, fiber scan versus ultrasound, motility studies, anal rectal manometry, and EMG. Guys, some of you don't do all of these, some of you do everything. So again, it can be any of those that we see more so in the GI world. So let's talk about Bravo. This is a pH electrode placement, that's what this is. Since October 1st of 2009, CCI policy, which is correct coding initiative policy, this is updated every year, usually January, and the updates are usually in the CCI policy at least by December 15th, all right? And it says that if you're just doing an EGD to place a Bravo, that's not considered diagnostic purposes, it's just for guidance and it's not separately payable. So providers must document any other reason for performing the diagnostic EGD, not just to place the Bravo. The patient has symptoms, and oftentimes this is the first time you're seeing this patient, first time you're scoping this patient. So why are you doing it? Do they have epigastric pain? Do they have heartburn? What's going on with this patient? Per Medicare, the service must be billed and the place of service or the location the beneficiary received the care, and that's been since 2013. 91110 is GI tract imaging, which is wireless capsule. And as of January 1st of 2015, CCI policy also states that the endoscopic placement of the capsule is not separately payable unless done for diagnostic or therapeutic purposes. All right, also modifier 26 should be added when placed in any other site other than the office setting. And again, back to policy in 2013, all right? If the ileum is not visualized, the modifier 52 should be added. And this is very important, guys. If the patient covered a previous upper GI endoscopy and colonoscopy were negative, now this is a payer issue. Almost every payer that you deal with has policy on capsule endoscopy. And they have their guidelines. They have their guidelines on what's covered and what is not. Aetna has policy, and I think Aetna's policy on a lot of their things are 20, 30 pages long. And they all have something that says not considered medically necessary or considered experimental when. All right, so you always need to be double-checking to make sure that your providers have documentation to support medical necessity. So we're talking about a previous upper GI endoscopy and colonoscopy. Some providers say it has to be, or payers say it has to be within a year. Some have to be during the current episode of care. And some also require small bowel follow-through. Also some of the payers give you approved diagnosis codes of what's covered and what isn't. It's so important that everybody in your practice, specifically your providers, all right, know what they have to document, what's considered medically necessary, and also for whoever does preauthorization as well. You know, so now why are you scheduling this to be done endoscopically? All right, the patient refuses to swallow, make sure that they're aware that this is not covered, and that you would need an ABN form if there is a issue with an esophageal stenosis. If they have a gastric outlet obstruction, if they have gastroparesis in particular, that is pertinent information that needs to be documented as to why an endoscopy is medically necessary. All right, so capsule endoscopy of the colon was new for 2022, and it includes the visualization of the duodenum, esophagus, ilium, or stomach. And then you also have to document why the capsule had to be placed endoscopically. All right, again, the kind of the same guidelines, and it's not covered by all payers at this time. All right, a lot of them are considering this as an experimental. And we had that when we got the first capsule code of 9-1-1-0 back in 2003, and there's still some payers out there, still some payers out there that have issues with coverage for capsule. All right, so question number one. When billing for capsule endoscopy, what place of service is used for Medicare when the capsule is placed in the outpatient hospital setting? Is it place of service 11, office, place of service 21, inpatient hospital, place of service 22, outpatient hospital, or none of the above? Yep, remember for Medicare, it's where the patient had the capsule placed. All right, so the place of service would be 22, outpatient hospital. All right, good job. All right, infusions. Okay, guys, this is probably, and Krista mentioned this earlier, this is probably one of our areas that we want to get right. We are seeing recovery audit contractors going after practices. We are seeing payers want to look at pre-patient records for pre-authorization. And then, again, before the payment is rendered, so they're in a prepayment review situation as well. So, again, we still need the basic demographic information, but we have to have the diagnosis or chief complaint. Krista had mentioned, be specific as possible, location of the IBD, the location, or any manifestations associated with it. Now, this is not just infusions for IBD. This can also be for what? Iron replacement therapy as well. So, the ordering physician, and this is the, by the way, this is the provider in your practice. This is listed, and you would find that information in box 17 on the 1500 form. We had one of our practices get pulled into a RAC review for this, and they actually had to pay back money, or let's put it this way, there was an attempt to recoup money because the provider that was listed in box 17 was not a provider in their practice. All right, we're not talking about an infusion center. We're talking about a physician office-based infusion. All right, so you have to have a order from a physician in your group because this is considered an incident to service. All right, somebody in the office ordered it, and you're following through in giving it. All right, the supervising physician also is the billing provider in the office suite, place of service 11. They are not in the endoscopy center upstairs next to your office, et cetera. They have also got to be in the place of service 11. The physician orders in the medical record, the best practice is to list this on the infusion record with like 10 milligrams per kilogram, et cetera. Name of the medication with the NDC number has to be on the claim, the serial numbers in the infusion record with the expiration dates, the current order including the name of drug, dosage, and frequency, the strength, the dosage, the total units given, the total units discarded, the site of the injection or IV placement, the route, the start time. All right, and anything over 15 minutes is considered an infusion. So if you do not have a stop time, you cannot bill an infusion service. Rate of administration, the volume infused, the name and the signature of the clinical staff provider, which is the RN, the name and signature of the supervising provider. If more than one separate infusion is given, there's a start and stop time for each infusion. In vital signs, obviously, patient response is kept as like in a diary form as well. All right, so these are just some tips for infusions. When administering multiple infusions, injections, or combinations, you only are able to bill one initial service code that day. The initial service code that best describes the primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur. So it says if an injection or infusion is of a subsequent or concurrent nature, even if it's the first code, you would bill that as a subsequent. So guys, if Benadryl 50 milligrams IV push is given prior to the infusion of Remicade, each additional IV push code for the Benadryls 93775 will be billed because the main reason the patient was coming in was for the Remicade infusion. And so you would be billing the 96413 for the first hour of Remicade. All right, so you want to report the services as well as the codes for the specific substances provided. The fluid used to administer the drug is considered incidental hydration and is not separately reportable unless you have a contract that states otherwise. Talked about the 15-minute rule. Okay, just because your physician or provider went into the room doesn't mean that you can bill a visit unless there was a chief complaint or an issue that occurred unrelated or separate from the infusion. That's Modifier 25. It's kind of like a howdy visit, just seeing how you're doing. But if you're actually adjusting medication, if you're investigating patient's complaints, you're doing something above and beyond just seeing how that patient's doing through the infusion, it is separately billable. A nurse visit cannot be billed, all right, if you're giving an injection infusion unless you're doing something other than that. All right, Medicare does not pay for infusions for any other site of service other than office. We may have some commercial payers pay with the site of service ASC, but that is subject to contract negotiation. And when you look at an approved procedure in the ASC, infusions are not considered part of that. All right, so it has to usually be a contract situation. I mentioned this before, the physician or provider must be on-site, place of service 11 in the office suite. Now, a nurse practitioner PA can be considered a supervising provider, but you just have to know that payers will discount that rate 15% for the infusion. And we do have some other commercial payers, specifically, it seems like it's Medicaid, that will also discount your medications 15%, which they should not be doing. That's not a provider-based service, but just make sure when you're checking through on your reimbursement that you're getting paid accordingly for this. Prior to administering any medication that is extremely costly, you always want to make sure that your payer is going to pay you at least your cost, all right? If not, then will they provide the medication for you? The JW modifier, I kind of talked about this earlier, and this is actually a modifier benefactant since 2017, that any type of discarded drug and biologic has to be submitted on a second line, all right? We are starting to see some commercial payers also want that documented as well. And the JZ modifier, which is new and will be effective January 1st, but mandatory by July 1st, don't have a lot of information on that just yet. So, for an example, on Remicade, if you're giving 400 milligrams of Remicade of Crohn's, of the large and small intestine, and you're giving oral Benadryl upon arrival, you have administration time of three hours, you're going to be billing 96413 and 96415, one unit and two units with a diagnosis of K50.80. Your J1745 is for your Remicade, all right, 40 units based upon the milligrams of dosage. It's calculated at 10 milligrams. And oral medications are not separately billable. All right, so this has to deal with hydration for somebody with volume depletion, all right? The Remicade administration was three hours, hydration was an hour and a half. So, you have a total time of four and a half hours, right? So, we have 413 for the initial because their main reason is for the Remicade, 96415 for two units, and 96361, which is each additional hour for hydration services. Now, important is that you have actually assigned the diagnosis code of hypovolemia to support the reason for hydration services and your dosage of Remicade. This also talks about discarded solution. So, in this one, we would do 96413, 415. Five units was discarded, 95 units was given. We used J1745 and J1745JW. There was also Benadryl given. So, we can also bill the 96375, which is the sequential IV push, and J1211, or J1200 for the Benadryl. These are some of the biologic agents for IBD. And we do know that SkyReasy still does not have an approved J code. It's a generic J3590, and you would list the total milligrams given in box 19, which is your comment field. And some of the iron infusion agents are listed as well. All right. So, polling question number two. The billing provider for infusions for services is the provider who is in the office suite during the entire infusion. True or false? Yep, it's absolutely true. They have to be in the office suite during the entire infusion. Those are the guidelines. Okay, pathology services. All right, and I'm not going to go into a lot of detail between pathology and anesthesia. I'm just going to go over the basic things. All right, we know that the name and location facility has to be documented. This is broken into professional and technical. If the pathologist is billing with the 26, that means all they're doing is the interpretation. The lab is billing with the TC. That means they're processing the specimen. If you're billing both services, then you bill without any modifiers on this. We do have to have three dates on a PATH report. The date the specimen was obtained, was received, and was processed. The ordering physician is usually the endoscopy provider. There has to be a clinical history, and that's important. All right, it should be specific. It can be based on symptoms, personal history, family history, any chronic diseases that the patient's being scoped for. All right, if there is no clear indication, all right, and that has to deal with a pathology requisition, then the endoscopy report should be requested. Oftentimes, if we're working with an endorider, the pathology requisition is dropped after the endoscopy report is completed, and it usually takes information from the endoscopy report and sends it to the pathologist. So, if the endoscopy report isn't clear, guess what? The pathologist doesn't get any decent information to report it as well. So, it's kind of like I said earlier, what starts the whole process for pathology is actually the endoscopy report. So, if you're having issues, if the pathologist is having problems determining medical necessity, this is something that maybe needs to be discussed with the ASC site and the pathologist together. All right, the location of each specimen has to be documented. The indications for stains, why is a stain being done? All right, so that information also comes from your doctors as to why did they biopsy this? So, what are they ruling out? What are they biopsying this? And then the pathologist needs to, is the one to determine whether an additional stain is required. All right, these are just some of the common stain types that we see. 88305 is the basic stain. And then we have 88312, fungal bacterial, 313 is for metaplasia. And then immunostains are broken down to 88342 for the first immunostain to the same specimen. And 341 is each additional immunostain to the same specimen. We do know that payers are looking at medical necessity for stains, so it's very important is that we have detail in the report to determine why the stains were medically necessary. Microscopic description is what our pathologists are responsible for on the pathology report. Size and margins. The gross description can be done by the pathologist or the tech, and that's how the specimen looks to the naked eye. Color, detail, shape, size, et cetera. There's also a diagnosis section and a synoptic report. And last but not least, the signature of the pathologist and the date of interpretation has to be documented. Now, there are focus on stains by most Medicare carriers, and most of our Medicare carriers have LCDs on these. All right, so make sure that your pathologists are aware of this. And I think this is the takeaway from this, is ordering special stains or IHC stains prior to review of the routine stain is not reasonable and necessary. It says, for most esophageal, gastric, and duodenal specimens, it is not reasonable or necessary to perform special stains. So again, it is up to the pathologist to determine whether or not the stain needs to be done. And most of the Medicare and CMS auditors are looking specifically at stains associated with upper GI endoscopy. We don't see a lot associated with lower. All right, so I'm not going to go through each one of these. These are just some of the recommendations. All right, make sure that this is just an overview. And I just mentioned those already. When screening is the indication for the procedure, that should be the primary diagnosis in order to trigger preventive benefits. You would think, but unfortunately, there are some payers that will not allow screening in primary position on PATH. So you would have to utilize your comment field, which is box 19, and enter screening converted to surgical endoscopy in order to trigger a preventive benefit for that payer. Make sure that you do not assign the D12 codes without pathology to confirm that this is a neoplasm. All right, so if pathology doesn't confirm it, it comes back as hyperplastic, then you would just be filling your standard K63.5 codes. All right. Conscious sedation and MAC. All right, so on anesthesia services, we obviously need the demographic information, we need the patient's diagnosis. We need the specific procedure performed. And I can honestly tell you, when we look at anesthesia charges, the documentations on some of these are not very good. All right, so what was actually done? All right, the findings during the procedure also need to be on the endoscopy, or I'm sorry, anesthesia record. The diagnosis to support medical necessity, and this is key, guys, because we have a lot of payers that will not cover MAC. They say there's no lax medical necessity in there. So just because your doctor likes to give propofol doesn't mean that the payer is going to cover it. So, guys, it's very important that medical necessity is established. Comorbidities, so important. We also have to have the ASA class documented, the position of the patient, the type of anesthesia, the start and end time for anesthesia care, and documentation of any discontinuous time, the name of the anesthesia provider, and if the anesthesiologist is supervising a CRNA, the name of the CRNA and the name of the anesthesiologist have to be on the medical record and signed. All right, so these are the guidelines for signature requirements. That's a link to the Meddler Managed Products. And also, guys, there is a separate anesthesia CMS. It's kind of a nice little MLN tool as well, the guidelines for MAC. All right, so conversion factors for anesthesia codes. That's $21.56 per unit, and the final is $20.61 per unit for 2023. So, again, that's a reduction as well. Whether or not that goes through, we'll see. These are the five codes we look at. 00731 is for upper, and you can see the base units are five. I don't believe a lot of you do the 00732 unless you're doing your ERCPs in the ASC. 00811 is anesthesia for lower GI endoscopy procedures, and it has a base units of four, and this is diagnostic. 00812 is for screening colonoscopy, and it says report 00812 for any screening regardless of ultimate findings, and that is three units. Anesthesia for combined upper and lower, so these are doubles, and the base unit is five. So, your billing time is based in minutes. Additional 15 minutes, 16 to 30, 31 to 40, et cetera. Most of our payers like the units based upon the total time spent for anesthesia services. All right, if you're looking at an ASA category of ASA3, that can be reported as a P3 modifier, but if the patient's on Medicare or a Medicare replacement plan, you would use the QS for the MAC, all right? The P modifiers are not submitted to Medicare, but to the commercial payers unless instructed otherwise. All right, so 00811 is used on patients undergoing diagnostic colonoscopies. All right, for Medicare purposes, the PT modifier should be added when screening is converted to surgical in order to waive the patient's deductible. So, they differ from the CPT guidelines. CPT says regardless of findings, Medicare states if you convert, you have a finding during your screening, we allow you to bill the 00811 with the PT modifier. The patient will still be responsible for the 20% currently, all right, but the deductible will be waived. Most commercial payers do not follow CMS policy, and they only want this used on diagnostic procedures. Some commercial payers want this code used on patients with a personal history of colon cancer or colon polyps because they consider this surveillance or diagnostic, not screening. You have to know what your payers want, and most of the payers that are following the Affordable Care Act want 00811 for personal history of polyps or personal history of cancer. All right, 00813 is used on patients undergoing doubles. There's really been no additional guidance for this code, and it does not accept a 33 RPT modifier. The best thing you can do is add screening in the primary position to see if it will trigger a preventive benefit, but do not be surprised if it will not. All right, so this is the guideline for your ability to bill the 00811 when screening turns into diagnostic. So conscious or moderate sedation. The code that we really should be reporting to the majority of our payers is G0500, and this means that you are doing conscious sedation, moderate sedation services provided by the same physician performing a GI endoscopic service that sedation supports. It's the initial 15 minutes of intra-service time, patient age 5 or older. All right, there's other codes, 15152 and 53. 152 is 5 and older, but that is not specific to GI endoscopic procedures. All right, so this was actually a transmittal back in 2017 for G0500, and it's stating that if you're doing this for screening procedures, so if you're billing this with a G0121 or G0105, you would add a 33 modifier to G0500. If you were billing this with a surgical endoscopy, all right, so screening converted to diagnostic, all right, then you would add a PT modifier to G0500. So these are just a couple of examples here. So for the first one, 67-year-old Medicare patient presents for screening. The total sedation time was 16 minutes. We would bill G0121 and G0500 with a 33 modifier. And the next one is when a patient has a screening with a polypectomy. So 45385 with a PT and G0500 with a PT. July 1st of 2017, CCI edits stopped paying 99152 when billed with any GI procedures because their systems were updated to accept G0500. So guys, will all payers cover sedation services? No. If their fee schedule wasn't modified in 2017 or 2018 to drop the anesthesia work value, they're not going to cover anesthesia services at all because you've already got them built into your procedures. All right. Do you guys know this question? Know the answer to this one. If a patient has a history of an MI nine months ago, what ASA category would be assigned? Okay. Well, it's not one, all right? And it actually is ASA three. All right. And the reasoning behind this is if you go into the ASA guidelines, anybody that has had a history of MICVA or stent placement within at least greater than three months are considered ASA three. If it's less than three months, these folks are ASA four. All right. So is it very important? That's where the history comes into play, asking our patients past history. You know, so if they had a history of a heart attack, we do need to know how long ago it's been because whether or not we're allowed to do certain endoscopic procedures is based upon whether our facilities will allow ASA three to be done in your ASC. And most of the time ASA fours are done in the hospital setting. So it is very important that we have a lot of this information. All right. And a little bit, I'm just not going to spend a lot of time on this. This is for dietician services. So 97802, 803, and 804 are only allowed to be billed by registered dieticians. All right. And they're billed under their NPI numbers. And Medicare does not recognize these codes for any condition other than diabetes or renal disease. So a lot of times if we have registered dieticians in our practices, it's a cash-based situation. All right. So if this patient is not Medicare, then really we should determine whether or not this patient has eligibility and benefits for that outside of renal and diabetes. If you're doing this dietary education by your advanced practitioners or even your physicians, you're going to just use your standard E&M codes based on time and counseling and coordination of care.

anesthesia

pathology

documentation requirements

diagnostic studies

medical necessity

sedation services

payer guidelines