I think it's time for the Q&A. Very exciting. Are you guys ready? There's a few questions in the queue. And there's a few. We will try to get to as many as possible. And if not, our faculty can certainly respond in writing during the event as well, but we'd like to share them with everyone. Our first question is, if you use G0105 for family history of colon cancer, do you use PT33 to show it as it is preventative if the patient has never had polyps? On the G code? Is that what they're asking? Yeah. G0105. No. So you don't need any modifier on the G0121 or the 0105, because it tells the payer. That tells the payer it's screening. Those are specifically meant for screening colonoscopy or high-risk colonoscopy. Yeah. G codes don't require any modifiers. Only if you're converting it to a surgical endoscopy would you need the 33 or the PT modifier. Okay. Our next question is, what if the decision to abort is made in the sigmoid colon or prior to the splenic flexure? You can blame CPT for this one. They changed the guidelines back in 2015 that if you cannot advance beyond the splenic flexure, you're stuck with a flexible sigmoidoscopy. Dr. Lindenberg, can we get that tree chopped down somehow in the CPT? You can submit an application to CPT for a change. We would support it. It's frustrating and hard to explain. What happened is they revised the reimbursement for modifier 53. It used to be when we added a 53 modifier, we used to get paid the same amount as a flexible sigmoidoscopy. Well, then they revised the guidelines and basically stated that you had to get to the end of the line. Otherwise, you had to either get to the cecum or the colon, small intestine and anastomosis. If you got beyond that, but you didn't get all the way to the end, that 53 now triggers a 50% reimbursement on it, where it used to pay somewhere around 27% with the same amount of the flex sig. When they revised that, then they also changed and said, okay, so if you can't get past the sigmoid or I'm sorry, the splenic flexure, then we're not talking 53 here. We're talking just a sigmoidoscopy code. Our next question is, can you address modifier added to claim for when you need to come back to do another colonoscopy due to the polyps that were not able to be removed on the first colonoscopy? Is this necessary? If there were polyps still left in there, no, I mean, you're just going to, it's going to be diagnostic. Yeah. So no modifiers necessary. I think I mentioned earlier, there are no frequency guidelines on diagnostic. As long as there's medical necessity, we see that a lot of times there may be a large polyp removed, maybe even during a screening. And then doctors want to make sure that everything's still okay within six months. And they bring that patient back in six months to re-examine that site. There's no problem with that as long as medical necessity supports it. Our next question is, can we bill a 43248 or 43249 for dysphagia with 43239 for biopsies? Recently, the 43239 has started to deny as global. So that, there are CCI edits in place for dilation and biopsy. Dilation and biopsy. So the biopsy has to be taken outside of the dilation zone in order to bill it. So documentation must support that. So then if it does support that the biopsy is done outside the dilation zone, you can bill both, but modifier 59 or XS would be added to the biopsy. And then ordinarily would be a different diagnosis. Yes. Right. Yep. So again, diagnosis pointers, you know, for the, for the dilation, you're going to bill like stricture or dysphagia, whatever the biopsy, it should be gastritis or something like that. Okay. Thank you for that. And our next question is for EMR demarcation. I've heard that high definition white light endoscopy slash chromo can be used to identify the edges of the lesion. That's correct. It doesn't change anything about your coding. It really just means you're delineating in some way that could be visually. It could be by chromo. It could be by using the tip of a snare and leave some marks around the edge of the polyps so that you know where, where you're going to put your resection margins. So it doesn't affect your coding though. Thank you. Next question is, my docs are starting to do endoscopic full thickness resections. Do we use the same guidelines for EMR and ESDs for this new procedure? It's usually considered the same similar guidelines for ESD, which is an unlisted procedure code. Yes. And Kristen went over that in her presentation. And Kristen went over that in her presentation. You know, you would, you would pick the anatomic area. You would put a list of procedure based upon that. Thank you. Next question is, can you address modifier 59 and XS? Do we need to use both? Does this depend on the payer? So you don't want to use both. It's one or the other. Okay. So those X modifiers are extenders to modifier 59 that gives the payer a little bit more information as to the scenario. So we typically have practices have better luck with modifier XS. But modifier 59 is still, you know, an acceptable modifier as well. They just, you got to make sure that it supports separate lesion or separate area. Documentation, so. Okay. And just, just to do a little time check here, we have crossed over a little bit into our, our, our lunch hour. And we'll just go a few more minutes since there's so many questions. And then, you know, your questions won't go unanswered. We'll answer them in writing, but let's just take a few more before we break for lunch. So the next one is we've got a PATH question here and they say high grade dysplasia is benign. Decode, yes or no? Okay. This is, this is actually where I get the doctor or the provider involved on this one. I mean, we've got obviously Barrett's diagnosis code has Barrett's with high grade dysplasia, et cetera. We also have some dysplasia codes for metaplasia in there too. But as far as when you're looking at a colon polyp or a colon polyp, or something in that matter, you know, high grade dysplasia could actually turn out to be what's called a neoplasm of uncertain behavior as well. But before I assign anything outside of benign, I always ask the doctor or the provider. Dr. Lindberg, what are your feelings on that? Well, high grade dysplasia are malignant cells. Um, so there, there is ambiguity and how you would potentially build this. I mean, some people would consider it a cancer or let's say you're doing a follow up exam. You could potentially use personal history of colon cancer. So I don't think there's any clear cut delineation here. I really don't. I haven't seen any guidance that I'd call definitive that that sort of stuff doesn't come from AMA or CPT and it doesn't really come from CMS and ICD-10 folks. You know, it's a different government agency and they don't issue a whole lot of clarifications on nuances. Thank you. Great discussion. Our next question is when performing recurrent pancreatic necrosectomies on a patient, are we billing the same codes for each procedure? Is there a limit to the number of procedures that may be performed on a patient? Until or unless we come up with a code or set of codes that covers how to do this, which we're working on, but it's complicated because there typically are a series of codes. And the first one often has to do with the placement of the specific kind of, like the axial stent that was in Christian's example. And the subsequent procedures really have more to do with the necrosectomy through the opening you've made. So right now, you'd be using the same unlisted code and submitting it. Subsequent procedures might have a different complexity than the initial one, but not necessarily. So I think you have to look at the situation of what you do. But right now, there'd be separate procedures from my view, but all using the unlisted codes. Thank you, Dr. Littenberg. Our next question is, what do you bill for EGD with placement of brachytherapy probe in the esophagus? I'd probably utilize the 43241 where you're placing a tube or catheter in the GI tract. There isn't real clear definition of this. I don't think it's been a CPT assistant article or anything of that sort. But to me, that's basically what you're doing. Okay. And our next question is, when billing for ASC procedures, and they specifically give us examples 45380, 45385, 43239, is it appropriate to bill findings first or the indication? All right. Um, we usually recommend findings. All right. Maybe with the exception of screening. Because we do know that some payers want screening in the primary position just to trigger benefits, but not all payers do. We want to make sure that our diagnosis code supports the instrument used as well. You know, so we're looking at polyps, we're looking at like for control of bleeding, you would be looking at some type of, say, ulcer with bleeding. So it kind of helps to make sure to validate treatment, especially if you're doing for multiples. So if you're billing for 45385 and 45380, which is a common occurrence, we'd like to have the finding for each one is the primary diagnosis, you know, and it would help to support the instrument used. And utilize indications when they're not significant findings. At least, of course, in the medical necessity for the procedure. The general ICD-10 principle is to be as specific as you can. So if you have more information, that's what you use. So if you have a finding that's more specific than the indication in most cases. An example would be for that is on an upper, for instance, say the patient has, let's say heartburn. Okay, and the only finding we have is a hiatal hernia without obstruction. If we put that hiatal hernia and it is a primary, then technically that's not considered an approved indication for upper gynecoscopy. Only if you have a hiatal hernia with obstruction of some sort. So in that situation, I would go back to the indication as your primary with the hiatal hernia as a secondary diagnosis. Just, that could be an example of when you could use an indication as your primary. And our next question is, is Z09 or Z08 for office visits only? Or does this apply to procedures as well? I think it can apply to procedures as well. I mean, it's just, it's probably a payer issue following guidelines. So it could, you know, if they're going to kick out Z86-010 as a primary, as a primary diagnosis on an office visit, they could definitely do that on a procedure as well. Well, we've seen, we've had quite a few questions that about G0105 by Cigna, not allowing Z86-010 as a primary diagnosis because it's not considered a principal diagnosis. So yeah, and we know Cigna will want that Z09 in front of it, whether it is done in the office, an office visit or a procedure. So if they're, if they're truly following the ICD-10 parenthetical advice, they're going to follow it, whether it's a visit or procedure. Okay. Our next question is, if I do EGD and necrosectomy through Axios, was placed in previous procedure without doing EUS, what code should be used? And then I think they speculate here, will be unlisted procedure plus what RV view comparable code. Yeah, again, that was pretty well covered by Kristen with some good examples. Again, unlisted code. And you know what, whether you use EUS or not, I mean, you'd factor that into the total work potentially, maybe the comparable RVU, but it's still an unlisted code. Right. And our next question is, does medical mutual pay for G codes? Ooh, you have, I have to get on the policy. I do know that medical, I've had, we've had practices that we've audited in Ohio, and this is a, this is a insurance company in Ohio. It is managed by Aetna. So I would, I would, I would say that they would accept G codes because Aetna does follow the guidelines and accepts the G codes. Okay. I think this goes back to one of your polling questions, Kristen, should we keep the letter to one page? Oh yeah. I, you know, as far as the letter of medical necessity for the advanced, your unlisted procedures. Yeah, I would keep it as simple as you can make it to where the, where the payer kind of understands. I wouldn't do any kind of lengthy letter. Yeah. The only thing I might add to that is if you've got a physician that actually has helped to create that letter. And I usually recommend that they do that is if they have any kind of clinical trial status or any type of clinical guidelines, you can attach that. Yeah. You can attach it in addition to the letter to support the point of view as well. Yeah. It's good to just put a link to a PDF article, as long as one is available online to be able to download. So you're not having to submit, you know, huge numbers of pages of information. But if it only exists, you know, on paper and you can attach it in general, you know, payers allow emailing in things. So it's not that big a deal, but it's good to kind of keep it succinct, but put references with links to articles that support medical necessity and procedure details. Some medical directors who are typically in the line of reviewing these have familiarity with them. Some, you know, you may have a pediatrician or a psychiatrist who's acting as a medical director. He'd have no idea what a pancreatic necrosectomy would be about or how complex it is or what an ESD is compared to a standard colon and snare polypectomy. Our next question is fiber scans being done for elevated liver enzymes. So R7401 and R7402 are getting denied. What are guidelines for billing with these codes? And these are payer specific. And most payers do have some policies on fiber scans. You know, I think fatty liver tends to be one of the things that is covered. And not everybody accepts the abnormal elevation of liver function studies as well. California, we're not having much problem with that because sometimes that's as specific as you can be after the fiber scan is read. You may not show fatty liver. You may not have a final diagnosis. So sometimes you can't get more specific than that, but it's still a good reason to do a fiber scan when you know you have a chronic liver test elevation. So it's worth appealing if you get a denial and, you know, that's as far as you can diagnose the case. But, you know, many of those situations you will find a fatty liver or you come to some conclusion about what the nature of the liver disease is.

medical coding

billing

modifiers

colonoscopy

EGD