All right, so let's go into the Q&A, and we've got a few questions in there. So I'll go ahead and read them. And number one from Aaron, can we review the possibility of billing same-day consult note with procedure? Also, if we are doing different site EUS F&A, is that billed times two? So this is kind of a two-part question. So billing a same-day consult note with the procedure, all right, Kristen, do you want to tackle this? This has to deal with modifier 25. Sorry, I was on mute. Okay. I just started talking. Yeah, so modifier 25, that is a big one that payers are looking closely at, more so the follow-up visits than the new patient visits and the consults. But if it's a new patient or a consult and you're making the decision to do that procedure or that service, then you can bill that with that 25 modifier. The thing you want to watch for, modifier 25 says significantly separate. And so that's what your documentation should reflect, is significantly separate service. So the only thing that, you know, if there's something that's pre-scheduled, you've made the decision to do it and you do that procedure that day and also try to bill a visit, that's not billable. That's bundled. Okay? So just like hemorrhoid banding, let's just take that one. That's a good example of, you know, day one, I see the patient, it's a new patient, I decide that they need to undergo hemorrhoid banding. Okay? I can bill that visit. They come back next week for the hemorrhoid banding. I shouldn't be billing another, I should not be billing a visit, just the banding, unless the patient says, oh, doc, I've had this heartburn and it, la, la, la, but the diagnosis for the visit would be heartburn. But yeah, it's got to be significantly separate. We have been seeing payers that actually look at the diagnosis codes also submitted on the claim. So we've always proposed, we've always, you know, basically said that best scenario is to bill the visit based upon the patient's symptoms and to bill the procedure based upon the patient's findings. All right? That's definitely helpful. That's how it gives the payer, it's like, this is what I preplanned. We saw the patient first. We had to go through a lot of data. We waited through a lot of stuff in order to figure out what we were going to do with their patient. Now, there are some unfortunate, sometimes the procedure doesn't give us any significant findings. All right? So especially in the hospital, it doesn't matter where you're doing this procedure, it has to do with the modifier 25. So if our doctors are seeing the patient in the hospital with, say, GI bleed, acute blood loss, anemia, and they decide to do an EGD that day, all right, they are addressing more than just the decision for the EGD. You know, they're looking at the data, most likely going to run serial HNHs and stuff like that. So that visit is separately billable. Sometimes we don't find the source of bleeding. All right? So we're still stuck on utilizing the GI bleed code or the acute blood loss anemia on the endoscopy procedure. But like Kristen just said, usually those initial visits are not usually what they're tackling. So we're talking more about the follow-up care. All right. Go ahead. I was going to say an example of a situation where you wouldn't necessarily be doing a hospital-based visit, even though you're doing an endoscopy is when we're called to the ER for a patient with an esophageal foreign body, generally, we know in advance, we're just going to go in, we're going to do the endoscopy for the foreign body, the decision's already been made. You call your staff and you go in and you meet them when the procedure is set up to do. You do take a limited history and brief physical exam yourself. And you're kind of making a medical decision making, yes, this patient is stable to proceed. But that's the E&M work that is really part of the procedure, because you're always doing a brief pre-op evaluation assessment, decision making, yes, this patient is suitable and stable enough to have the endoscopy. That's part of the pre-service work of any procedure. And you do that for the follow-up hemorrhoid banding, how you've been doing since the last time, how much bleeding have you been having, if any, you know, whether you're taking uricillium as we talked about. So there is pre-service and post-service work with the procedure. And that's what the idea is. It needs to be clearly separately identifiable that it requires more than just that typical work. Okay. Also, if we're doing different site EUSFNA, is that build times two? Unfortunately not. All right. That has a limit of one in the fee schedule, that only one can be built. If that takes you additional time and effort to do, if you're doing more than one of those, we could possibly add a modifier 22, which means more complex, extra time associated with it. But both of those components have to be documented in your endoscopy report. Payers look at both of those aspects. And remember that when you look at the Medicare fee schedule every year, there is a zip file that you get with it. And part of that zip file concerns the time components, the time allotments that are built into each code. And if you haven't done that, and you haven't gone to the CMS site to download the fee schedule, you really do need to look at that. For the ASC side, it also tells you like the approved procedures in ASC. But I like to look at the time components because that you'd be interesting to see what's factored in to say a snare. The work value is 30 minutes. All right. We also have the total preoperative evaluation time, the time to prep, the time to visit with the patient beforehand, the time to talk to the patient afterwards. And I think it's like 56 minutes total. I could be wrong about that. Encompasses the entire colonoscopy experience. But in order for a payer to actually award you additional revenue, they're looking at your work time during the procedure. So usually, in order for a 22, it has to be at least 50% longer than the time factored into that procedure code. So that is a possibility that you could add a 22 to that, but you can only build this one time. All right. So the next question is, can you explain what does this $33.06 mean for the conversion to the RVUs? I did explain that earlier. I'll go over it again. The $33.06 is multiplied times the total RVUs that are awarded for the procedure or the service that you provide. All right. And so if the service is awarded eight RVUs, eight times $33.06 is what the Medicare approved amount would be. That's national approved amount. All right. So if you look into your approved amounts, you have to base it upon your locality. And that's pretty well visible when you go into your Medicare carrier's website and find out exactly what your amount is going to be. Okay. To clarify, waste from ASCs is not billable, correct? This is just for professional claims? For the most part, yes. A lot of the medications that we give in the ASC are not separately billable. All right. So when you actually, when I was talking about earlier on the Medicare fee schedule, there's one for the ASC side, and there's several tabs at the bottom of that. And one of the tabs actually includes medications that are separately payable in an ASC. So that's what you would need to look at. The JW and the JZ modifiers talk about services provided in an outpatient setting. ASC could actually be considered part of that, but again, only if you're allowed to bill for those medications separately. All right. If the patient has a positive stool test, should we append the preventive modifier or a G-code when doing the follow-up colonoscopy? That's a good question. Unfortunately, I have no magic wand for this one. I'm going to talk about that a little bit when we go into screening versus diagnostic. Even though this has been mandatory since May, since May 31st by the commercial side, we don't really have specific guidance on this, so it's kind of a trial and error situation. So we've heard from our clients across the U.S. that they will allow a GO-121 for the screening with a Z1211 and an R19.5 if it's a positive stool test. All right. And then we also had somebody say that they billed as a GO-121 with the same codes and they got a denial back from the payer that they had already exceeded their screening allowables, all right, because they already had paid as a screening benefit for the stool study. So I'm, you know, this is kind of where there's possibly a glitch in that software system most likely, because if this is an Affordable Care Act policy that the patient has, it should be covered. All right, so this is one of the copay issue, too. You may get covered for your procedure, but then the patient may get billed a copay, which they really shouldn't be. So there are a lot of problems here, and it's not clear how you sequence things and so forth. And that'll be discussed a little more later. But this is something we don't have a clear-cut solution to, and coding edits and software may not have adapted to new regulations. So technically, whoever's responsible for looking at your denied claims or your processing payments, et cetera, should be watching closely for these patients. We always recommend pre-authorization be done, and then eligibility be verified just to make sure that that payer does have coverage, you know, has updated their policies, and the patient's plan does follow the Affordable Care Act. There are still some plans out there, the privately funded plans, that don't conform to the Affordable Care Act guidelines. So fortunately, they're fewer and far between than what they used to. All right. All right, I can take a few of the questions. Looks like some of these are E&M. Yep. And Dr. Littenberg, I might get your opinion on this question here, is bodily function, which is, that's under the Complexity of Problems Addressed for high-level. Bodily function, can this apply to loss of continence? It technically is. I mean, it is a loss of bodily function. But, you know, remember, you've got to have data or risk, you know, to support that overall high level. So, Dr. Littenberg, is there anything else you would add to that? I think a lot of it depends on the severity of the problem for the patient, how much it's impacting their functions, and, you know, if they're trapped at home, they feel like can't go out any place. Yeah. The more you make it seem like a complex and major problem, you know, comparable to somebody who's got, you know, a severe irritable bowel, and how is that impacting their life, et cetera, then, you know, it's a more complex problem for that patient if they've tried many things that they failed. So, again, the more complex it is, I think, you know, you base your complexity based on that, but you need to document those aspects. If the patient has not been seen for more than three years, that would be billed as a new patient. Does reviewing my old records for more than three years count as data reviewed? Unfortunately, you know, they're very clear that it has to be an external record review. So if it's your own records, unfortunately, you cannot count that in the data component. You can count it towards your time if you're doing a time-driven visit, but, yeah, unfortunately, it doesn't count. Can you... Oh, this is a good one. Can you bill for a patient who has multiple visits in preparation for screening colonoscopy who does not timely comply? For example, we send recall notices, they make visits, we order colonoscopy, patient cancels, a year goes by, and it happens again, and it repeats itself. So there is a visit prior to screening colonoscopy code that we can use. So when it's medically appropriate, and this is not Medicare, this is payers under the Affordable Care Act, there's S0285, that is the visit prior to screening colonoscopy, that can potentially be billed, but you're dealing with a noncompliant issue, which I believe is medically necessary. You know, for Medicare purposes, you know, I don't know I'd have to actually look at the documentation to see what's been talked about, what's been discussed, but if the patient's completely noncompliant and they have to come in to have that discussion and the importance and all that other stuff, then, you know, it definitely could be medically necessary. But there is that S0285, that's consultation prior to screening colonoscopy. And then the diagnosis codes you would use is screening Z1211, family history Z80.0, and then family history of colon polyp Z83.0, is it 71? I think it's 71. But any, Kathy, you want to add to that? I mean, those are the only, by the way, those are the only three that are covered for S0285. Personal history is not an approved diagnosis code for that. Right. If you order a CBC for that visit, and your office notes shows your order, do you still have to write it in your plan order CBC? As long as it's in your note, if I know in your note that you ordered it, then you don't have to regurgitate that same information. I'd have to look at your note to see how that's truly relayed in your note. Okay. If it's a screening colonoscopy with cardiac diabetes complications, will it be 03 or 04? No. Okay. All right. Are you managing it? That's the answer to that question. If you're not managing it, but you're sending the patient in for cardiac clearance, then it does not count. It's still considered either that S0285 or for Medicare purposes, not billable. All right. You have to manage that patient's condition. So if you are adjusting, say there's a relto, there are eloquence, et cetera, you're telling the patient to hold that, you can bill for that. All right. As far as what level you would bill, again, I'd have to look at whether or not the patient was symptomatic, et cetera. Most likely, most likely it would be a 03. It's one chronic problem that you are managing. All right. Even though the risk for that procedure would probably be at least moderate, all right, it's still not going to be able to get you anything higher than a level 03 service. All right. So if you're just telling the patient to take their blood pressure medicine, the morning of the procedure that is considered normal preoperative instructions, and that doesn't count towards hypertension management. If you are telling your patient to reduce their insulin the day before the prep to adjust their hypoglycemic medication, then yes, you are managing their diabetes for even a short period of time. But guys, that means your documentation and the impression and plan has to be clear. And so for like for the Xeroxo or the Eloquus, you would use that code, say Z79.01, which is current use of anticoagulants, but also why is the patient on this? So you would have another diagnosis, the AFib, the history of MI, the history of DVT or pulmonary embolism or whatever. Those codes should be on it. And screening would not be your primary diagnosis. Your management of the patient's condition would be primary. Agreed. Okay. All right. So when I do my hospital assessment and plan, do I need to use CPT codes for the problem or just say, for example, abdominal pain, RGI bleed without a code in my note? Yeah, you don't need codes in your note. Yeah. As long as you document, just document what the patient is coming in for or whatever, you know, the levels of services and the diagnosis codes, those will all be transmitted to the claim. But yeah, you don't need to include any kind of codes on your note. Okay. Next one. I may pick on Dr. Littenberg to help us a little bit with this one. Yeah, this is difficult. I do underwater EMR and do not do submucosal injection. Do I still get credit for EMR? Well, EMR in its CPT descriptor doesn't really say what are the components of it. Okay. Just says colonoscopy with endoscopic mucosal resection. But if you look in the description within the RUC database, you look at the procedural work involved. EMR involves doing submucosal injection and using some type of special device, a cap-fitted scope or some specialized snare for removal of a polyp. Now, there are nowadays techniques where we just put a lot of fluid within the colon and we're kind of working in a surface. The scope is sort of underwater. We're doing the colon removal by either snare with cautery or without cautery, without submucosal injection. And unfortunately, I don't think this would qualify for an EMR. It's really just a snare removal of a polyp, whether it's cold or hot. So this is not EMR. So you really need to be doing submucosal injection and theoretically using one of those specialized snares or a cap for EMR. And this has been a problem with this whole area of what's EMR versus a simple submucosal lift and snare removal, which are two different CPT codes. The CPT code for the snare removal, CPT for the submucosal injection. That's still not EMR. So these are kind of three different circumstances here. The one described here is snare removal, period. EMR is, as I said, with a specialized device as well as a submucosal injection. But then if you're not using any specialized device, you may be building the two codes for the snare removal and the submucosal injection separately. Okay. Thank you. I know this is a question we get quite a bit because there's not a lot of detail on EMRs. All right. So biotherapeutic agent. Would hydrogen peroxide during necrosectomy count? I'm not exactly sure. I think if you're referring to the ICD-10 code for that, that just means that you're managing a patient on monoclonal antibodies, et cetera. So if you're doing H2O2 irrigation or injection during a necrosectomy, that's just considered part of it. Yeah. What I talked about is instilling a biotherapeutic agent that's specific. Oh, okay. Enema of fecal microbiome for clostridium difficile. If you're billing for pancreatic necrosectomy, during which a lot of times different solutions are injected within the pseudocyst to help do the debridement. There is no CPT code for pancreatic necrosectomy right now. This is all billed using unlisted codes or some combination with pseudocyst drainage codes. So you would not be trying to get separate credit for instilling some agent. It's all kind of part of a package of what the necrosectomy involves. Our societies are going to probably submit a code proposal for necrosectomy during this next year, meaning. Thank you. A couple of years off before we would get that if we're lucky and whether they work RVUs involved will be sufficient remains to be seen. So right now, those doing necrosectomy, hopefully you've worked out things with your payers for an unlisted procedure. Okay, we've got about three more minutes till break and we've got quite a few questions left. So let's go ahead. How do we bill for endoscopic sleeve gastroplasty? It's pretty well an unlisted procedure code. You would use 43999, which is an unlisted procedure of the stomach and comparable. What would you consider the comparable procedure code to be? It's going to be an open approach that you would have to compare it to. Yeah, sleeve gastroplasty surgically would be kind of the closest, but you're not doing the 90 day necessarily as part of it. So you kind of subtract the value for some of the E&M services and look at the time involved for the actual procedure sleeve gastroplasty that a surgeon might do laparoscopically. And that would be what you try to explain to the payer is what should be comparable work and value of it. That kind of a similar answer for the next question. Is there a code for endoscopic suturing? Again, there is no specific code for it. Suturing can be done in a variety of contexts. So in this case, you have to use an unlisted code depends where you're doing the suturing, which unlisted code you'd use and have to explain it to the payer. It could be repairing something that happened during a procedure. That's even trickier to get payment for, because theoretically, you don't separately bill for fixing complications that you've created. But if you're, let's say, reducing a gastric outlet in a patient who had a prior gastric bypass and it's gotten all stretched out of shape, they've regained weight. You may be suturing them to restrict the outlet. You again, maybe a gastroplasty procedure, et cetera. So that needs to be worked out case by case with unlisted coatings with your receipt. So with your payer. So you can need to be extremely detailed about what you're doing, how long it's taking to do it, general complexity of it, and negotiating. Okay. What do you bill for a patient who has transferred ERCP from an outside hospital and will be transferred back to the outside hospital where he or she is admitted? I think I'm not exactly sure of the question, but the place of service is actually where the patient is. Right. Where the patient had the encounter. Yeah. Yeah. I would comment here that if it's known in advance, you're going to do an ERCP and the patient gets transferred over to you. Usually you have enough records that you're not needing to do an entire new patient yourself or hospital evaluation yourself. So this would be a situation where you generally be billing the procedure, but you wouldn't be billing for the 25 modified hospital on kind mostly. Now, if the patient arrives in bad shape, they have active cholangitis. You need to manage their sepsis. They're not stable for the procedure. That's another matter. But if simply a patient who's stable, common duck stone, the doc who tried it at the outside hospital, or where they didn't have the ERCP services, they transferred the patient to you to do the ERCP. They're stable. You know what you're going to do. There wouldn't be a separately identifiable E&M service. I can grab the next one. Okay. Let's kind of do three more, and then we'll break. Three more and break. Yeah. Guys, we will answer all your questions, but there are a lot of questions coming in, but we'll get to them at least before the end of the day. All right. For Cigna, not allowing history of polyps is a primary diagnosis code. Is this just for office visits, or does this apply to colonoscopies as well? If for colonoscopies, then would it be primary diagnosis for a surveillance colon when the reason is due to a history of polyps? More frequent than a true screening. All right. So it could be a couple of issues. Are they, if they're not allowing it strictly as a primary diagnosis, and I'm going to actually, I have a slide on this in my ICD-10 presentation. They want the Z09 added primary to personal history. Okay. So it's a follow-up after completed treatment. So Z09 plus Z86.010. If it's a situation where they're allowing it, but patient has more out of pocket, that is just because personal history can be considered more of a surveillance and not covered under screening benefit, and that's up to the payer policy on that. And I'm sure Kathy's going to address that at our next talk. Yeah, we're going to talk about that more in detail. I'm not exactly sure what this next question is. I'm going to go back and see if she. I'll go back and see if I can find her question. And I think, Dr. Littenberg, you had already answered this one. Yeah. Is ER consult billable for foreign body removal? Well, let's say the patient, ER calls you, you come down, you talk to the patient because they're having chest pain, and they think maybe something is stuck, and you're not really sure. You're not sure if you're going to be needing to do an endoscopy. You may decide to do something else. Then you can certainly go for the evaluation. But if it's clear-cut, patient has a foreign body, you know you're going to do an endoscopy. They've been worked up by the ER physician. There's already whatever lab or EKGs, et cetera, that are necessary. And you just have a brief chat with the patient just before you sedate them. And that's not a separately identifiable service.

medical billing

coding

same-day consult note

modifier 25

screening colonoscopy

S0285