I know we are behind and we've got a lot of information that we're going through and I, you know, so we're going to talk about diagnostic studies, infusion services, pathology, anesthesia, and touch a little bit on nutrition. So a lot of this has not changed, you know, the documentation requirements for any type of diagnostic studies, obviously, we have to have demographic information, you know, that's, you know, that's so important. We also have to have dates, the date the test started, the device placed and swallowed, the date of download is separate from the date of insertion. And you need to see above this, it says the referring provider and the ordering provider. One of the things that payers look at specifically is on the claim, there is a field called the referring provider in this field 17. You know, any type of diagnostic study that we do, any type of lab that we order, etc., requires that information and it should be originating within our practice. So the date the test started or the device was placed or swallowed, the date of download if separate from the date of insertion, the name of the facility, the indication for the procedure and study, the name and dosage of any medication or any type of radiologic substance, any type of description of findings, the impression and recommendation, and so important is the date of the interpretation and the signature of the interpreting physician. All right. So, so important. All right. Without that, we cannot go for that test. All right. So what data service should be assigned for any service that is broken down into the professional and technical RBUs? And those codes are actually in the 51,000 section and the 70,000, 80,000, and 91,000 categories. So per CMS, which was last updated on February 1st of 2019, if we're billing as a global service, then the date can either be the date of placement or the date of interpretation. So global means we own the equipment and we also do our interpretation. So for billing as interpretation only, Modifier 26, the date of service is the date of interpretation. For billing as technical only, which is Modifier 20 TC, the date is the date of service or swallowing placement. Now for the commercial side, this is a spreadsheet issue, all right? Some want the date of service or the date of interpretation, even if it's a global situation. So we need to check with all payers to see what date should be submitted on the claim. And again, back to the spreadsheet. So when we're looking at GI-specific studies, we're talking about manometry, we're talking about pH and Bravo studies, we're talking about impedance, we're talking about capsules, we're talking about liver elastography, fibroscan versus ultrasound, motility studies, anal rectal manometry, EMG, just to name a few. So when we look at the Bravo, this is actually, and I think most of you know what this is, it does have an attached electrode placement, all right? So since October 1st of 2009, the correct coding initiative policy that you'll find is in Chapter 11, the EGD is not separately payable with the placement of the Bravo unless it's done for a truly diagnostic purpose, not just for guidance, all right? So your providers have to document, our physicians have got to document other reasons for performing the diagnostic EGD, not just to place the Bravo. And a lot of times, this is actually a lot of times the patient's first EGD, all right? So per Medicare, the service must be billed in the place of service, the location, the beneficiary received the care. 9-1-1-1-0 describes GI tract imaging, all right? And this is a capsule endoscopy. We have kind of the same issue with this for endoscopy as well, because as of January 1st of 2015, CCI policy does not allow for separate placement of capsule unless it's done for diagnostic or therapeutic purposes, all right? We add modifier 26 on this when the device is placed in any other site other than the office setting, and that's for policy since 2013. If the ileum is not visualized, modifier 52 should be added. And this is probably the most important part of this. It's only covered if previous upper jandoscopy and colonoscopy were negative. And the problem with this is, is how long ago does this count, all right? And I think this is kind of where some of our providers have issues, because even with the capsules, we are seeing a lot of payers that actually want to look at documentation to make sure that this was done, and when it was done, and what were the indications for this. And some also require that a small bowel follow-through also has been done. So again, some of your capsule vendors will provide you with a spreadsheet, and they update it usually yearly, that will give you information as to medical necessity, documentation requirements, et cetera. All right. These are just some guidelines for the colon capsule, all right? Not all payers cover this. So polling question number one, when billing for the capsule and jandoscopy and your place of service is 11 office, what modifier is required when you are providing the capsule and your provider is doing the interpretation? Is it modifier 26? Is it TC? No modifiers required? Are both the 26 and the TC? Okay, 67% of you say no modifiers required, and that is correct. All right. All right, documentation requirements for infusions. And I know some of you that are doing infusions, this is probably the most time, just so much time to get these infusions covered, and then also to get them paid. It's kind of a two-phase situation. You know, documentation requirements, pretty well the same thing, demographic information. We need to have the chief complaint, the diagnosis has to be specific, not just Crohn's. Crohn's is a large intestine, small and large, small, et cetera, same for ulcerative colitis. Artering physician has to be the provider in your practice. I kind of told you about that earlier. For the other diagnostic studies, it's also required for infusions as well. All right, this infusion is considered an incident to service, which means that it is given after your doctor provider saw the patient and initiated the treatment plan. The supervising physician is your billing provider is in the office suite, the place of service 11. All right. The physician order into medical record. All right. This is one of the key things that the payers are looking at. And I think, you know, I think we sometimes, when we talk about the providers and the payers in particular, some of us, some payers require way more information in order to get the claim paid. United Healthcare and Blue Cross and Blue Shield are the two that seem to require more information for infusion services. And one of the things they are looking at is the order. And another thing they were looking at is is to when the patient had the TB test, as well as the hepatitis B vaccinations, too. So those are the things that they do look for. So making sure that whoever has to submit the documentation for payment of the claim knows what needs to be sent. So the name of the medications with the NDC on the claim and then the serial numbers have to be also contained in the infusion record. We need the current order, including the name of the drug, dosage and frequency, the strength, the dosage, the total units given, the total units discarded, the site of injection, the route, the start time. And remember that injections are billed when there is less than a 15 minute administration time and anything over 15 minutes is considered an infusion. So we're talking about the rate, the total volume infused has to be a stop time. Without a stop time, you cannot bill an infusion. All right. We also have to have the name and signature of the RN, the name and signature of the supervising provider. And obviously, if there's more than one separate infusion given, there has to be a start and stop for each one. All right. And we have to have a diary of vital signs in the patient's response to that. So just some guidelines and tips. So just because your doctor or provider went into the room doesn't mean that you can bill a visit. All right. And this has to do with the modifier 25 situation. Unless there was a chief complaint or issue that occurred unrelated or separate from the infusion. A nurse visit 99211 shouldn't be billed just because the patient came in for infusion or injection. This would have to be some other indication besides the infusion. Medicare does not pay for infusions for any site of service other than the office. Commercial payers may pay with the site of service 24, but that is subject to contract negotiation. And again, a provider or physician must be on site. Please service 11 office suite during infusion, not next door. All right. Not in the hospital, but in the office suite. Prior to administering any medication, it is extremely costful. And we all know biologics are extremely costful. Make sure that they're actually going to pay you for your cost. All right. And if the amount is less than your cost, you need to negotiate or you need to have that payer provide you. The medication. Now, there's some modifiers associated with infusions. The J.W. modifier that's been in effect since 2017. All right. Has to go on any type of discarded drug or biologic. So it's a two line for the medication, one for the amount given, one for the amount discarded. Now, there's a new modifier, Jay-Z, that went into effect on July 1st of this year. And we're supposed to report the Jay-Z modifier when there are no discarded drugs or biologics. All right. So. OK. I have some examples on this one. So if we're going to give Remicade 400 milligrams and we're going to give the infusion of three hours, we build 964131 unit, 964152 units, and we would build J1745 with the Jay-Z modifier because there were no discarded medication. On example two, you can see that there was discarded solution on this one. We gave 95 units of Remicade and we also discarded five. So we have a two line items for this. All right. And these are just some of the biologic agents and the associated J codes for this. Iron infusion agents. You can see there's three of them. All right. So true or false. The billing provider for infusion for infusion services is provider who is in the office suite during the entire infusion. You are correct. Eighty five percent of you are correct. That provider has got to be in the office suite during the entire infusion. OK. Pathology services. All right. Again, the name and location of facility has to be on your pathology report, along with demographic information of the patient. All right. If the pathologist is billing with a 26 modifier interpretation, there should be report with his or her practice name at the top of the report. If the lab is billing with the TC modifier. There should be a report with the name of the lab who processes the specimens at the top of the report. Sometimes it's not. It can be contained, especially if you are not part of the pathologist group. If the service is billed as a global service without the 26 or TC modifier, the name of the practice should be on the top of the report. Date a specimen is obtained has to be on there. The date specimen was received in the lab, and the date specimen was processed. So there should be three dates on that. The ordering physician, the referring physician, and there should be a clinical history. Everything actually starts with the endoscopy report. All right, so there should, you know, it should be symptoms. It could be personal history, family history. If there is no clear indication on the path report, the endoscopy report should be requested. And if this becomes a frequent issue, then there is an issue in communication based on the requisition. Okay, could be a physician issue, could be a software issue, but it needs to be taken care of because this is one of the issues that we've seen some practices with pathology claims have had is that if it's a missing history on that path report, there's recoupment. There's no medical necessity. The location of each specimen, the indications for stains, so important. All right, and then the stain type. All right, these are just some of the stain codes that you would associate with this. The microscopic description has to be on the report, and that's done by the pathologist. The size and margins, the number of units and specimens, and the gross description. All right, also should have a final diagnosis. And sometimes we'll see a synoptic report, and Kristen mentioned that before, that it says clinical correlation. It's required, et cetera. And last but not least, and the most important is there has to be the signature of the pathologist and the date of interpretation. We all know that there's a special focus on stains by most Medicare carriers, and I'm not gonna go through all of these slides on here because this has actually been in effect since 2013. And one of the biggest things on here is they're saying the ordering of special stains or IHC stains prior review of the routine H&E stain is not reasonable and necessary. So it's like, we just don't stain everything willy-nilly. All right, there has to be some type of step process for this. Okay, so I'm gonna skip these slides in here. And then just recommendations. Just make sure that your pathologist providers and administrative staff are aware of this policy. If for colonoscopies, when screening is the indication for the procedure, that should be the primary diagnosis in order to trigger preventive benefits. And honestly, I was just looking, there was a question and Kristen said basically that she was gonna answer that was the number one. It was Blue Cross Blue Shield of North Carolina. While I was pulling that policy up, while Kristen was talking about that, and they have their own policy on screening colonoscopies and they will allow for pathology Z1211. So that's probably one of the payers that does because not all of them will allow the Z1211 for a pathology diagnosis. So when polyps are removed in either the lower or upper and lower GI tract, if they're not adenomatous, if they're in other words, they're not neoplastic, then you use the stomach polyp codes. All right. Talk about anesthesia. All right. So again, we need the demographic information. We need to have the pre-anesthesia risk assessment. We need to have the findings that were found during the procedure and probably highlighted, I probably should highlight it pink, italicize the diagnosis to support medical necessity for anesthesia. Comorbidities should be listed in the order of priority. And again, this is a spreadsheet issue. Some payers only want the comorbidities for MAC. They don't care that the patient has a positive or they have iron deficiency anemia. They wanna know why anesthesia was necessary, an anesthesia provider was necessary, why MAC was necessary. So again, which diagnosis code goes first? We need to know the ASA status, the type of anesthesia provided, the position of the patient, the start and end time for anesthesia care. The documentation of one anesthesia provider to another, the name of the anesthesia provider, as well as the signature. You must include a legible form of the name and credentials and all documentation including signatures should be complete and legible. And if you want more information on the signature requirements, I have the link to the fact sheet for this. So for 2023, the conversion factor is $21 and 12. On cents per unit, the 2024 conversion factor is $20 and 43 cents per unit. All right, so you basically can see on the next five lines, the what the base units are. So for 00731, it starts as five units. So that's five times $21 and 12 cents. That's what the approved amount would be. All right, any additional units are based upon 15 minute intervals of time. Okay, now that 2043 is the current amount that could change pending any adjustment to the final rule. So we've got 811, which is diagnostic colonoscopy. 812 is for screening. And it says regardless of ultimate findings, right? So you can see a difference, four units versus three units. And then 00813 is a double, right? The base unit is five. And you can pretty well see on here that these are the units in addition for 15 minutes and 16 to 30, right? For CRNA services, if the patient is on Medicare, Medicare replacement plans, we're gonna use a QZ for a CRNA. We're also gonna use a QS for MAC, all right? We don't use a P modifier to Medicare. The P's are usually correspond to the ASA status. If we're dealing with a commercial plan and the patient is ASA3, then we can use the QZ modifier and the P3 modifier. Okay, 00811 is for patients undergoing diagnostic colonoscopies. These are patients with symptoms, abnormalities, chronic diseases. Now for Medicare, and this is really important that we can actually use the PT modifier on 00811 if a diagnostic colonoscopy or if a screening was done and a polyp was removed. The 00812, all right? And most commercial payers do not follow Medicare and they still wanna have this used even if a polyp is found. So this is again, another spreadsheet issue. You want to make sure that you figure out who wants what on this, right? And 00813 has been problematic simply because you're doing an EGD and possibly a screening on this patient. And it does not accept, that 00813 does not accept the 33 or the PT modifier. So oftentimes this patient's going to have some out-of-pocket responsibility. G0500 is moderate or conscious sedation codes. This is billed under the physician performing the endoscopic procedure. It requires the presence of an independent trained observer which is the RN, all right? And it's the initial 15 minutes of intra-service time. All right, this is what we submit on our claims. I know you can see these slides here, the 99152, which is 15 minutes, age five or older. But since July 1st of 2017, the 99152 is bundled and it's not separately billable with any endoscopic procedure, all right? Because they say the G0500 is the acceptable, acceptable procedure. So this is just an example of how you would bill conscious sedation service. So if you've got a screening colonoscopy and moderate sedation was done, we would be billing G0121 and G0500 with the 33 modifier. So the patient's copay undeductible will be waived. So if it's a 65 year old Medicare patient and a snare polypectomy was done, we would bill 5385 with the PT modifier and G0500 with the PT for moderate sedation services furnished during a screening colonoscopy which turned therapeutic. So the patient's deductible is waived but the 15% copay still applies. All right, we know that not all payers will cover sedation services if their fee schedule wasn't modified or in 2017 or 2018 to drop the anesthesia work value. And we know that Medicaid for the most part also does not cover anesthesia services or sedation services. All right, so if a patient has a history of an MI two months ago, what ASA category would be assigned? Is it ASA2, ASA4, ASA3, or ASA1? And I know I didn't go over this a lot but I'm just checking to see what you think it would be. Oh, kind of a split one on this one. Indeed, yes. Okay, this is actually ASA4. All right, so, so important. Anything less than three months is considered ASA4. Anything greater than three months is considered ASA3. So important, guys, when you're asking and taking a history. I think the doctors and our anesthesia providers know this but I think this is so important is if you are working in the practice, et cetera, and we're trying to assign an appropriate modifier on this and trying to do pre-authorization for this patient, this would actually qualify for outpatient hospital monitoring, all right? So, and ASA4, and we know ASA4 is not done in our ASC and it's definitely not done in the office setting. Okay. Dietitians, and I'm just gonna, this is gonna be brief, simply because of the fact that the matter is some of you have dietary counselors in your office and these are trained dieticians and certified dieticians, registered dieticians. So we've got three codes to bill it by. It's 97802, 803, and 804. And only thing that Medicare covers right now is renal or diabetes. These, I've got a link for their Medicare coverage guidelines in for this. And we know that a lot of times we are doing for celiac, we're doing for IBD, we're doing for diverticular disease. And some of you are doing for weight loss, all right? But again, we don't normally do the education for diabetes or renal. So if we're not dealing with a covered condition, it's cash pay. And if we are actually doing and utilizing our advanced practitioners to do this, or even some of our doctors do the counseling, then those are just codes based on time in the office. All right, but if you have a registered dietician, your patients need to be aware that this is a cash pay situation. All right, thanks guys.

diagnostic studies

infusion services

pathology

anesthesia

nutrition

documentation