So, the top 10 2022 coding questions received by ASGE. And when Eden introduced us earlier, she mentioned that both Kristen and I, we answer the questions on the ASG helpline. So what I did when I created this, I kind of went back through the previous year's questions. And a lot of questions are similar. So I obviously did not put down everything that we look at, but I pulled out a couple of them in here. So number one, our question is about the place of service for manometry 91010 and pH studies. The technical component is being done in an outpatient hospital facility, place of service 22. The technical component is of course being built separately by that entity with a TC modifier. Our gastroenterologists are doing the interpretation or professional component from our office, and we do the billing for that with modifier 26. The question is, should the professional component be billed with a place of service 22 for outpatient where the actual test was performed or the place of service 11 for the interpretation, which is being done in our office, but with no face-to-face contact with the patient. And this is similar. We talked about this earlier, and I even had a polling question on this as well. And the interpretation must be billed under place of service 22 for the outpatient hospital since this is where the test was originally performed. But this is a common question we get, guys. And one of the things is when you're looking at the RAC issues and the OIG issues, but under RAC, the place of service is something that they look at quite closely. Number two, our doctors are performing more and more colonoscopies and EGDs for Lynch syndrome. We are having a difficult time getting paid. Do you have any suggestions for me on how to code these? Oh, yeah. This is a problem area. Okay. These are actually subject-to-payer policies. Now, for colonoscopies, this actually is covered as G0105 or 45378 with a 33 modifier because it's considered a surveillance, and you can actually, some of the payers will allow Z15.09, which is the genital, I'm sorry, genetic predisposition, right? But some don't. When you look at the ICD-10 codes for this, it's not a primary diagnosis because it is. But some of the payers are looking for personal or family history associated with this. And if they don't see that, they don't actually approve Z15.09. So again, this is some of the payer policies. And your patient technically wouldn't have had testing for Lynch unless there was a family or personal history. So it's really important that your providers make sure that you're given this information and that the patients are asked these questions. Okay. EGDs, this is a problem because these are non-covered. There are no screening EGDs. So guys, even if you have findings during that EGD, and since so many require preauthorization now, you may not get this preauthorized. All right. So I recommend that you get an ABN or waiver form signed by your patient just in case and maybe understand that this may not be a covered service. So unfortunately, there is no magic wand for Lynch. It is definitely up to payer determination. All right. So number three, I do the billing for the physician who works primarily in an ambulatory surgery center. There are articles regarding the physician can bill the 53 modifier, but how does the facility code it? Modifier 74 specifies it's for extenuating circumstances that threaten the well-being of the patient. So the facility isn't comfortable using that modifier as a poor prep itself, since it's obviously not life-threatening. They're getting denials, of course. So they're wanting to have patients sign an ABN, which we know will end up with many patients canceling their procedures as they can't afford to pay the facility fee. I've searched CMS also with this, and they also mentioned the doctor's portion using 53. Do you have anything specifies legal ethical use for them to use modifier 74? The similar situation with procedures with a shorter recall than Medicare's two-year high-risk allowance. Once in a while, there's a patient that needs to have a polyp rechecked and might need more tissue removed. I was trained for the repeat procedure to only code the polyp itself. They're uncomfortable using that code if nothing ends up removed the second time and will only build the history up, which of course gets an automatic denial from Medicare from any Medicare insurance. So they're planning on having the patient sign an ABN also in these situations. What's your opinion? All right. So this actually was asked by a member under Noridian. So it says your Medicare contractor Noridian addresses both the 53 and the modifier 74. The definition of this modifier is not limited to life-threatening conditions. They state also to use this modifier for discontinued procedures. The definition of modifier 74 only includes discontinued procedures after the start of anesthesia. Now, CPT states to add the modifier 53 of the CEQAM and or colon, small intestine anastomosis was not examined. And so therefore it would also apply to the facility as modifier 74. All right. So guys, you know, it is not just considered a life-threatening situation. So you know, it's any kind of discontinued procedure after anesthesia started. If a patient comes back to check the active polyp site, then you should use the current polyp diagnosis so that D12 diagnosis would be correct. You would only use the 86.010 for personal history if the polyp was completely eradicated from the site. So what you're doing is you're looking at the path report. If there are considered, if they're actually positive margins, then that would support utilizing the polyp code. All right. Number four, I have a claim bill for 45380 with a primary diagnosis of K63.5 and was designed denied for this diagnosis is inconsistent with the procedure. The diagnosis on the claim was K63.5, D12.2, R19.5, K57.30 and K64.1. Can you help the insurance as well care? When you look at the diagnosis code, the K63.5 is the colon polyp, the D12.2 is benign neoplasm of the ascending colon, R19.5 is positive stool for occult, R positive fit or coligard, K57.30 is diverticulosis and K64.9 is a grade two hemorrhage. All right. So I don't believe in the insurance company is not really the problem. As Kirsten talked about this earlier, you cannot build D12.2 and K63.5 together on the same claim, since this is an exclude one edit per ICD-10. So if the patient has both an abnormal and a hyperplastic polyp, and you've got pathology back to confirm it, then you're going to build the most significant diagnosis of D12.2. Now this is a sidebar, diverticulosis and hemorrhage are considered incidental findings unless treatment is initiated in the plan of care and the colonoscopy report. Very rarely do I see that. All right. It's just like occasional diverticuli were noted and a non-bleeding hemorrhoid was also found. All right. And there's nothing in there concerning further treatment. Those are considered incidental findings and they do not necessarily need to be reported. So again, we're back to looking at parenthetical advice in your ICD-10 book that causes a the issue and making sure that you look and you check the denial reasons as well. We have been getting denials, number five, from UnitedHealthcare and Cigna when the auth we have doesn't match the procedure that was done. Is this something that others are seeing? Is the best practice to authorize every CPT code in the EGD family or colonoscopy family since we cannot predict the outcome? Unfortunately, yes, with these two payers. We have recommended that all procedures that could be done during endoscopic procedures be authorized. And U.S. UHC has been doing this for a long time. This is nothing new. Cigna just started it. This is a recent trend for them. You know, so if, you know, I mentioned earlier that Cigna had updated their list for screening colonoscopies and listed all of the additional codes that were allowed during that procedure. So those are what you would preauthorize. Anything that would have been found during that and look at the list for upper jandoscopy, there are like almost five times as many codes under EGD as there is for colonoscopy. It is a policy that just drives me nuts. But the thing is, is if you don't preauthorize this, they don't give you the ability to go back. There's no retroactive, you know, so it's, you know, after your doctor does this procedure and you didn't get this code preauthorized, you know, and now you're going to call and get a preauthorized and say, well, if you didn't get a preauthorized at the time of before it was done, then it's not going to be covered. You know, it's kind of got your hands tight. So you need to preauthorize any potential that might be done during that procedure. Number six, we would like to know which diagnosis code is more appropriate for an abnormal liver function test. In the past, we used R74.8, but should we be using R94.5? Honestly, this is probably one of the most common diagnosis code errors we find when we do reviews. And a lot of times it's how your system was set up and the system was set up because of ICD-10. Actually, it was an ICD-9 issue and it just converted to an ICD-10. So R94.5, when you look in the ICD-10 book, is under the category, and if you look into the index, it's under abnormal liver function studies. But that's under the heading of radiology. So when your doctors are doing LFTs, it's blood. So ALT-AST is R74.01, LDH is R74.02, amylase lipase alphas is R74.8, bilirubin is R79.89. So what do you have to have your doctors do? They have to specify the enzymes elevated. If they don't, then you're stuck with an unlisted code of R74.9. So how many times when you look at notes, do you see elevated LFTs? And if you're wanting to preauthorize the RCPs or anything like that, it is important that you do know the exact elevation or the exact blood test that's elevated. Number seven, we receive referrals for EGDs prior to weight loss surgery with no signs or symptoms, the payers will not prior authorize or will deny for medical necessity. I always ask the provider if they feel the patient requires an EGD after their visit, and most of the providers say no, there is no reason for the EGD. I would like to help educate providers and patients regarding this issue, and I'm having trouble finding good reference. Well, this is a payer policy, and I had it actually earlier, that specifically indicates that asymptomatic patients prior to bariatric or non-gastroesophageal surgery is considered not covered. And when you look at other commercial payers that have upper GI policy, they have the same exclusion as well. So the issue with this, and kind of, sometimes I get a little cynical with this, but we don't see the bariatric surgeons do pre-op EGDs anymore, a lot of them used to, simply because they're not getting paid for them either. All right, so most other commercial payers, you know, when you're checking preauthorization, if it's not covered, the patient needs to be informed up front. If this is Medicare, you're going to have to have them sign an ABM form. If it's a commercial payer, you're not going to use a Medicare ABM. All right, the ABM is actually used on Medicare only and not Medicare replacement plans. So you're going to have to utilize either the payer has their own waiver, or you can create your own waiver slash ABM form, but you have to leave off Medicare or CMS's name on any of those. But make sure the patient's informed up front. Number eight, what kind of documentation is needed to bill an EMR? We've talked about this a lot evidently today, but this is probably one of the most common questions that we get. We are having difficulty distinguishing between a lift and a snare, and an inject and assisted EMR. Is it sufficient for the surgeon to document the word or abbreviation EMR? I have included an abstract of a colonoscopy report I've encountered, a very large polyp measuring about five centimeters in size with a broad base, somewhat semi-pedunculated at a difficult location in the sigmoid at 40 centimeters was found. The polyp was removed in piecemeal manner by endoscopic mucosal resection after saline and epinephrine injection, followed by a combination of cold and hot snare polypectomy. The base of the polyp was fulgurated at the end with the tip of the snare. Three hemoclips were applied at the site. The site was tattooed using Indio ink injected in the opposite wall of the polyp. Technically, all the documentation in there really does support the EMR. The term endoscopic mucosal resection is very important in the description of the procedure itself. It's much more involved than just a simple saline lift and snare. We said this before, that payers are often request records before payment is made to make sure that an EMR was actually performed. We also have an issue that a lot of payers consider this a second step, our staged service, and they'll also pen to claim, even when it's submitted with the PT or the 33 modifier. We've seen an increase in reimbursement on the ASC side. It's a little bit more than double because of the extra instruments and costs involved during that procedure. There is an increased amount. As far as what our doctors get paid on it, when you're looking at Medicare reimbursement, you're looking at a little bit more for an EMR than you are for a snare and a lift. When you're looking at the commercial reimbursement, it's a little bit more for the snare and the lift, but that should not trigger how you bill this. You should bill it exactly for what you did, but your documentation has to be complete. Number nine, I billed an unlisted code for fistula closure and Medicare denying my unlisted code is unprocessable. I did not notate anything in box 19. This is my second time using an enlisted code. I am not too familiar with them. Would I appeal on the Medicare portal with documentation? When you bill an unlisted code, you have got to fill in box 19. You have got to put something in the comment field or it comes back as unprocessable, which means you have no appeal rights whatsoever and you have to start all over again. You'll have to do an errand logging adjustment. You're going to start all over, and then when you resubmit the claim, it's going to be a brand new claim. You're going to still use an unlisted code, and you're going to put in endoscopic fistula closure in box 19. Then you're going to get your explanation and benefits. You're not going to get paid on this, but it will prompt you to send documentation and say further information required. All right, so that's guys with anything. Anytime you see an unlisted procedure code, all right, you're going to have to fill in box 19. You put in like endoscopic necrosectomy. You're going to put in endoscopic fistula closure, endoscopic GPOM, all right, anything that we don't have an actual CPT code, we're going to have to build an unlisted code. You have to fill that in. Otherwise, you can keep sending and resending and trying to submit, and you will not get through. It's just unprocessable means that you have no appeal rights. You've got to start over. All right, number 10. I generally code with GO-121 for average risk and GO-105 for high risk, regardless of age or insurance company. I never use 45378 with the appropriate screening diagnosis. My team members do use the 45378 with screening to report and only use G codes for patients over 65. We do get paid for both scenarios, but I just wanted to make sure which is the correct way to report. Well, most payers except for Medicaid and some regional payers except GO-121 and GO-105, and you'll find this on their website on the list of approved codes on the screening colonoscopy policies. All right, we recommend that you use the G codes because if the payer accepts that, that's automatically going to trigger your preventive benefit. So the best practice on this is to use the codes that are more, let's put it this way, more appropriate for the preventive benefits.

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