Okay, so I think after listening to myself and Kristen, Dr. Lindenberg, I think we've kind of been focusing on medical necessity, and that's what the payers are really looking at. They want to make sure that the documentation supports why you're doing certain things, why you're seeing the patient, what levels you're billing out, et cetera. So we're going to talk about medical necessity, diagnostic EGD policies, infusions, E&Ms, the principles of medical record documentation, ICD-10 specificity, and some endoscopy tips. So guys, I think as we go through, it's kind of going to be a reiteration of certain things that we've talked about, and also maybe some new things that we haven't so far yet. But without medical necessity, you're going to have difficulty getting pre-authorization. We know that most payers are requiring authorization for endoscopies, Anthem was the first one back in 2018 that started pre-authorization requirements for EGDs, and a lot of our commercial payers have followed suit. We have gotten multiple questions from various practice managers stating that their frustration level keeps increasing because some of the, you know, obviously the physicians would like to get these EGDs scheduled, but they're sometimes being put off a week to two weeks behind simply because of the fact that pre-authorization is not being obtained. That's all to the documentation or lack of documentation for medical necessity in the medical record. All right. So that is key. So without medical necessity, we know services won't get paid initially, oftentimes delayed, and sometimes won't get paid at all if there's no documentation to support it. And without medical necessity, we can face recoupment of previously paid services. You know, the top medical necessity areas of payer focus are diagnostic EGD, infusion services, hemorrhoid treatments, multiple endoscopy, pathology and special stains, screening versus diagnostic colonoscopy, and evaluation and management services. And Kristen touched on this a little bit, too. You know, but for screening versus diagnostic, and I mentioned, too, that your payers are looking at the claims history that the patient has. And sometimes that's what triggers a payer to review the note, even sometimes after they've paid for preventive benefits on this. Remember that they get audited, too, to make sure that they're playing claims appropriately. And so one of the areas that a lot of the outside auditors for the payers are looking at are screening benefits. You know, so did they really have to pay them? You know, so if the patient has had previous claims by, say, primary care submitted with GI bleed or rectal bleeding or iron deficiency anemia, and all of a sudden here comes the screening colonoscopy, that is sometimes what triggers a review, or it also prevents our claims from getting paid. So again, somewhere important that our documentation is specific and that we have the documentation to support the medical necessity for what we're doing. So let's talk a little bit about EGD, all right? One of the things that we sometimes, you know, are looking at are the PCP's record. You know, so do we have what we need from them? Do we have any partnered labs, any previous radiologic studies, or the patient's complete history? Sometimes we're missing that, and that's a reason that things have to be delayed, all right? So these are, you know, Anthem, Aetna, Tufts, Humana, UnitedHealthcare, just to name a few, all right, have upper GI endoscopy, and most do require preauthorization. So this is what their indications are, gastroesophageal reflux symptoms that persist or recur following an appropriate trial of therapy for two months or more. We see this, when I say we, Kristen and I, and when we're looking at endoscopy reports, we see that statement, gastroesophageal reflux symptoms that persist or recur, that's it, but no list of symptoms. You also have to list the therapy, what has been done. You know, this is what the payers are looking at, and this reflux symptoms is often a GI quick measure, especially on the ASC side that we see. You know, so you still have to, if you're picking that, that's fine, but also list the symptoms that the patient's having, all right? Persistent vomiting of unknown cause, that makes sense. New onset dyspepsia in individuals 50 years of age or older. All right, so if you're under 50, doesn't count, does it? I think dyspepsia is kind of a diagnosis we sometimes loosely use. When you look at the diagnosis code for dyspepsia, it is K30, and anything with K means it's a proven GI condition. Often the symptom of dyspepsia can be what, epigastric pain, it can be heartburn, et cetera. If you have not done a previous EGD for this, then you really should be utilizing the symptoms and not using dyspepsia, all right? So use your symptoms, unexplained dysphagia or adenophagia, signs or symptoms suggesting structural disease of the upper GI tract, all right? So that's another dropdown that we see that's often on an indication, but no symptoms are listed. So if you're picking this as an indication, you do need to also add your signs and symptoms in here. So they're saying like anorexia, weight loss, satiety, persistent nausea, be specific. Post-operative bariatric surgery with persistent abdominal pain, nausea, or vomiting despite counseling and behavior modification related to diet adherence, all right? So that means if the patient's had previous bariatric surgery, you do have to ask them if you're following your diet, what weight loss have you had, have you gained any weight, et cetera, that all has to be documented. Recent or active GI bleed, I mean, that makes sense, that's going to be covered. Not medically necessary, all right? So this is Anthem, all right? Anthem does allow for screening for Barrett. They're the only GI, they're the only payer that does. And they basically say it has to be a screening for Barrett's, all right? And it's men over the age of 50. Now, not medically necessary, and this is also Anthem in most of the payers, an asymptomatic upper GI tract on an average risk individual, follow-up screening for Barrett's esophagus after a prior EGD exam was done, all right? Surveillance for any of the following, healed benign disease, such as gastritis or duodenal or gastric ulcer, gastric atrophy, pernicious anemia, fundic gland or hyperplastic polyps, gastric intestinal metaplasia. Now, that has changed on some of our payer plans, but not all of them, all right? Previous gastric operations for benign disease or accalasia. Radiographic findings of any of the following, an asymptomatic sliding atrial hernia, an uncomplicated ulcer, any type of deformation of the duodenal blob. Confirming that H. pylori has been eradicated prior to bariatric or non-gastroesophageal surgery in an asymptomatic individual. Metastatic adenocarcinoma of unknown primary when the results will not alter management. Obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude Barrett's in adults. And that's kind of a sidebar. We already talked about biopsying normal peering tissue without symptoms for screening, all right? The same kind of applies it on the upper GI tract as well. So sometimes I just see there's an indication of dysphagia, that's it. But biopsies of the small intestine in the stomach are done of normal tissue. And nothing documented as to what you're ruling out and there's no symptoms to support it. All right? So guys, be very, very specific as to what differential diagnoses you have and list all of the diagnosis codes or all of the symptoms that the patient has to support biopsies of normal tissue. I mean, a lot of your patients might also have epigastric pain, all right? That would support it. Iron deficiency and hemia may also support it as well. List everything that's appropriate. All right, medical necessity infusion services. I talked a little bit about that during infusion. So I'm just going to kind of go over this again because we are seeing so many issues with this with payers pending your claims. You know, anything that delays the payment of these high dollar amounts, your infusion services themselves are not high dollar. I mean, sure, that's a good amount coming in, but nothing like the thousands of dollars that you're putting out for the biologic agents. So we want to get paid as quickly as possible on this. So do you have any documentation in the record to support the reason for any type of change of the biologic agent? Be specific as to lab studies and patient signs and symptoms. Anytime the medication is changed, especially if you're moving from one agent to another, pre-authorization has to be done again. If you're increasing the dosage from the one that was pre-authorized, you also have to obtain pre-authorization. All right, sometimes the patient's BMI changes, they've done very well, they've gained their weight back, and now they need a higher dose. That also needs to be pre-authorized as well from certain payers. Do you have a specific IBD condition documented? Do you have the result of the patient's TB test and vaccination status? And that's actually one of our clients got put into a potential recoupment because there was no documentation to support a TB test this time. It was in the record, it just wasn't within the documentation that was sent to the payer. So there are certain things when you guys get records for review purposes, for infusion services, you need to make sure that you have the current order in there, you need to have the status of their TB test status. We need to make sure that the name and signature of the supervising providers on the infusion record, we need to have everything documented. And if it's in multiple different folders within your system, then they need to be printed out and sent so the payer has all of that information in front of them. All right, we talked about the ordering physician. So do you have the ordering provider from your practice listed? The name and supervising provider and infusion record, all right, all that has to be documented. All right, so medical necessity for E&M services and making sure that your practice is looking at benchmarking reports, comparing them to national statistics and each individual providers to those statistics and your practice as a whole. All right, and Kristen kind of mentioned that before on the auditing, you know, making sure that you check on this, finding out if your providers are outliers. You get sometimes letters from payers that says, you know, Dr. So-and-so, you bill more 99214s than other peers. You know, your 99214s are submitted 84% of the time as compared to the national average of 47%. All right, so that means that they usually say, we recommend that you review your, you know, pull some records, review your notes, and refund any overpayments. That's kind of, in some of, if this is a CERT review, sometimes they'll actually give you a link to the Medicare sites for the E&M guidelines. They have E&M training modules on most of your Medicare sites as well, and so they also monitor that to make sure if they sent the letter, they're recommending that you take training on this. They will monitor, see if the providers do take training, but here, if you get a letter, they're also knowing that they're going to be watching your claims, right? So what are they going to be doing? Since you get the letter, they'll probably give you about 60 days in there, and they'll look at trends again to see, okay, on the level four, because this is what we were picking on, did your 99214s stay at 84%, right, did they go down? So if they see a dramatic decrease on this, or any decrease from what it was, you know, when they ran a report, and they usually look at a year's worth of data, they'll look at trends for this, and they go, oh, okay, they must have took our letter to heart. We see that they're going down, so we probably need to pull those notes, because they had coded them in correctly. All right, or, on the other end, they'll look, and they say, huh, there's no difference. They're still billing a majority of these visits as 99214, so guess what? We're going to pull those notes and look at them. So either way, guys, they're going to probably sample your notes just to make sure that your documentation supports the level. And Kristen mentioned this before, you know, undercoding is an error. So if you get nervous and think, okay, I better throw in some threes in here, and maybe a couple twos, and your documentation supported the level four, then you're also, you also have an error as well. All right, so diagnosis codes can also trigger a pay or down coding of the level of service. And the R&B News just published this last week that we're seeing practices reporting that commercial payers are lowering the level of visits, lowering the reimbursement, not denying your claims, but they'll actually, in your explanation of benefits, you build a 99214, but they'll pay out as a level three. The same with a 99204, they'll pay as a level three or possibly a two. Because sometimes what they're talking about is they're saying it's based upon the diagnosis code that you submitted or the lack of diagnosis codes that you might have submitted on the claim. So, for example, if you have an established patient visit with the diagnosis of GERD, and you submit it with 99214, but other diagnoses were addressed and not submitted and linked on the claim, all right, that may be the issue, right? They only saw one diagnosis, GERD. That's not usually a 99214 diagnosis. All right, so everything that you saw the patient for, remember, two or more chronic conditions support level four when you're doing any type of prescription management with that patient, right? A lot of times you are, right? So make sure that all of the conditions that you are currently managing be listed on the claim. The core elements of the E&M service, making sure that your diagnosis codes support the documentation in the medical record, decision making, again, should be triggering your level of service. If it isn't, then your time shouldn't be documented. And I had a question the other day that said, you know, what happens, you know, are payers if they're down on your level and you're billing by time, do they know that? No, they don't. So could you, if say, you billed a 99214 because 35 minutes of time, total time was spent with the patient, you might want to just go ahead and use box 19 in the common field and say 35 minutes spent in total time or total care of the patient today. That would support your billing that level of service. And it's something that you could also do. All right. So the assessment of the patient should be clear, include any details, do not code from a problem list, right? Problem list, sometimes there are 20, 30 conditions on there. You're only coding from the diagnoses that you are addressing, right, during that encounter. Remember that comorbidities and risk factors play a role in the provider's decision making. All right. And the plan of care should show an evaluation and treatment of each condition that you actually are supporting and listing on your claim. All right. The general principles of medical record documentation. Number one, it should be complete and legible. This is a review, right? The documentation of each patient encounter should include the reason for the encounter and relevant history, relevant physical exam, any prior diagnostic test results, the assessment, impression, the diagnoses, the plan of care, and the date and legible identity of the observer. If it's not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. Past and present diagnoses should be accessible. 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 should be supported by the documentation in the medical record. Now, these are the 1995 documentation guidelines. It's really still current. All right. The only thing that we're not doing out of this is assigning a level based upon the amount of history and exam elements. But all of this is still very appropriate. Remember that your medical record tells a story. It tells why the patient's coming in. It tells what you found and what you're going to do about it. And that's really the whole purpose of that note. It's a communication, right? So if the patient's reviewing the record, which a lot of them are doing now, you're giving them their visit information. You're sending that information to the primary care. They have to understand what you're treating the patient for and what you're ordering. It should be complete. It doesn't have to be a 23-page dissertation, right? But it's a record of what you're doing. It's so important. And, of course, you always, always have to worry about this being a potential liability down the road. All right. So true or false? Without a signature and a date of service on the medical record, the service cannot be billed. Absolutely, 100%. You're right. Okay. Got to be signed and dated. Good job. All right. ICD-10 specificity. I kind of mentioned this earlier. Kristen's gone through this as well. We're seeing an increase in claim denials because of the fact that most of the payers are looking very closely at the ICD-10 instructions. Lacks specificity. Lacks medical necessity. We mentioned earlier not a primary diagnosis is a new denial reason as well. An invalid ICD-10 code. We don't see that as much anymore, and if we are, it means your system has not been upgraded. Be sure and keep up to date on payer policies for medical necessity. Monitor your medical necessity denials closely. All right. You want to track the specific reason for denials. You also want to communicate this with your coding staff, your billing teams, and don't forget to bring your doctors and providers in on this. If their medical necessity is an issue, which means that their documentation did not support it, especially if you're trying to get any type of CT, MRI, capsules, anything like that scheduled and approved, you know, they need to be aware of this. It does affect overall patient and quality of care. Conduct documentation and coding education based upon denials, and then you want to make sure that your denial rates keep going down. I was in a practice two weeks ago, and, you know, they had on the board. They had what the AR is and what their AR for infusions were, and, I mean, that was spectacular. You know, it gets updated every month, and they had less than 9% in 90 days out, and that is just phenomenal. So, I mean, this is kind of what you're targeting. You want to make sure that everything's being reviewed, everything's being updated, and your providers have, you're communicating well with your providers. All right, so coding for medical necessity, making sure that you're specific with the Crohn's disease diagnosis and any manifestations. All right. We talked about the infusion issue already. All right, so if the patient has a longstanding history of GERD who presents for upper endoscopy to do persistent heartburn and epigastric pain, all right, that's kind of what you want to have in there, right? What's going on with the patient? That should be in your visit note, right, because, remember, a lot of our payers require preauthorization. They're looking for that one statement in there to support whether or not EGD is medically necessary. We can also code together the R1013 and the K21.9 on the claim as well. Hemorrhoids, I think we've gone over this a couple times. Be specific, hemorrhoid treatments. There should be documentation as to the patient's response, any symptoms associated with it. There has to be medical necessity, so it needs to be confirmed because hemorrhoids are one of the things that the payers are looking at. Comorbidities and risk factors. All right, so we're looking at documentation. You know, it helps to also back up that this is endoscopy with risk factors, all right? It also helps to support the need for MAC as well as HTC and risk adjustment. So this patient has a new evaluation of epigastric pain and bloating. You're going to have an outpatient diagnostic EGD. Patient is at increased risk for this procedure due to underlying COPD, coronary artery disease, and severe obesity. That's the kind of documentation we want to see that also helps to validate a higher level visit as well as the need for MAC. All right, so endoscopy billing tips. I know there were a couple questions that were asked, and I answered some of those that were listed in the question queue earlier. And one of them had to deal with how do we bill for a snare and a biopsy? So if we're billing for multiple polyps that were removed by the same technique, you cannot bill for more than one. So 12 polyps removed by snare cautery, we can only bill for snare. That's it. We can potentially modify our 22, but it has to have tremendous complexity and time to support that procedure. There was a question earlier. We were talking about an EMR. What if the EMR was done to different areas of the colon? How many times can I bill an EMR? You're kind of the same guidelines. You can only bill this one time. Can bill for each technique utilized to treat different lesions now. So if you had a snare in the sigmoid and a biopsy of the transverse colon, and be specific as to the instrument used for the biopsy, because that's another area that the payers are focusing on. If you're billing for a snare and a biopsy, they want to see whether or not the biopsy forceps were used, or jumbo forceps was used. Be specific as to the instrument used. We would add the 59 or the excess modifier to the bundled code. The biopsy is bundled into the snare. All right. And if you're not sure which code is bundled, and if they are bundled, then you utilize CCI edits or claim scrubbing software, and you can put those codes in. It'll tell you what's bundled and which one would take the modifier, as long as the documentation supports a separate lesion. So there was a question earlier about EGD with biopsy is bundled into any esophageal dilation code. Unless the biopsy is out of sight of the area of dilation or the dilation zone. Biopsy is also bundled into several ERCP codes, such as sphincterotomy, stem placement, and dilation. So again, if you're biopsying the site that you're dilating and stenting, we cannot bill that separately. You know, double balloon enteroscopy. And I know not all of you do this. If it's an oral approach, you're going to use the 44360 series. If the ileum is not visualized, the 44376 series, if the ileum visualized, if this is through an anal approach, and there is a diagnostic colonoscopy also done, 45378 and 4479, the enlisted procedure of the small intestine, can also be billed. The term endoscopic mucosal resection should be used when billing for an EMR with a full description of the procedure. All right. We know that the claims for EMR are often pended by payers. And what they're doing is they're verifying documentation of the endoscopic mucosal resection. Make sure the indications are clear. We talked about this. Just don't use upper GI symptoms. Be specific as to the site type of symptoms. Incidental dilation, dragging of the balloon during an ERCP is considered just, you know, a lot of times you're, when you're doing an ERCP, you're inserting the catheter, you're inflating the balloon, injecting contrast, and then dragging the balloon down for better visualization as well. All right. That's considered an incidental dilation, and that's considered part of your ERCP. If you're dragging it and removing sludge, debris, and stones, that's considered stone removal. Right. So a dilation can be billed in addition to stone removal, as long as it's not just an incidental dilation. So that means, doctors, you need to document that there was a stricture which had to be dilated before you could even do the ERCP. That's the kind of documentation that you have to have. Make sure to document location of each stent placed during ERCP because each one is billable. Document the cholangioscopy. Spyglass was used. This is an add-on code, not cholangiography. That's considered part of your ERCP. If you're doing interpretation of biliary and or pancreatic duct images, during ERCP, these are separately billable, as long as there's documentation to indicate that you personally interpreted the images. There's a static image on file, and there is no conflict with the radiologist also billing for the interpretation. So before you start billing it, make sure that that is clear. And you can usually look for the cholangiography or the ERCP report. Sometimes it's stated differently in the hospitals. But you want to look to see if it's signed by the radiologist and if there's interpretation. If it is signed by the radiologist, then there's a good possibility they also billed for it. So doctors, if you think that you should get paid for it, which I do believe you could, and CMS basically says, whosoever interpretation guides the further care and treatment of the patient is the physician that should be billing for that. I mean, it is appropriate for you to bill, but you have to make sure that there is no what? Conflict. And make sure that your documentation indicates that you personally interpreted the bile duct images or the pancreatic duct images or the biliary and pancreatic duct images without any what? Any assistance of the radiologist. Right, that needs to be in your report as well. All right, so when banding or treating hemorrhoids is done, a noscopy is included in the procedure and it is not separately billable. All right, and no bonafire will bypass that coding edit. Controller prevention of bleeding is bundled into every procedure, it is considered part of the surgical procedure unless it is completely a separate site or lesion. And I think Kristin already talked about this and Dr. Littenberg went on about this as well, but submitting an unlisted code for procedures, we need a cover letter to explain what we did. All right. Always list symptoms, which require diagnostic evaluation and differential diagnoses. Make sure all pertinent comorbidities are listed. And then make sure any specific indications are listed on your procedures. We all know that any lack of specificity or vagueness can impact your reimbursement. Anything that delays your payments costs your practice. The average cost of a delayed, denied, pended claim is at least $35 for each one. And it costs you money to research, to be on hold, and to submit another claim. All right, make sure all documentation is completed and signed in a timely fashion. You have state guidelines that, you know, that sometimes they say it has all signatures have to be done within 30 days of treatment or the visit or anything like that. Some are not, some do not give you complete documentation requirements. CMS basically states that your record should be updated as long as you have full and total recall of the visit. Again, just timely, timely, timely is so important. Keep up to date on all payer policies. Remember your level visit is justified by decision making and time. And last but not least, if you didn't document it, you didn't do it. All right. And thanks, and on to Dr. Wittenberg.

medical necessity

documentation

billing

endoscopy procedures

pre-authorization

claim denials

diagnostic EGDs