I'm going to talk about medical necessity in more detail. I think you kind of have heard us say medical necessity over and over and over and over again. And you know, it's the key to economic success, you know, so I'm going to talk a little bit about medical necessity as regards to E&M and then the principles of medical record documentation and then overall some endoscopy tips. So I think without medical necessity, the services won't get preauthorized. You know, this is a key thing, you know, when Kristen was talking about medical necessity and decision making, you know, that's important for establishing the level of visit, but we also want to make sure that we have the necessity for endoscopies, for CTs, for MRIs, for capsules, et cetera. We see more and more payers that are actually requesting the record, or more and more payers ask for documentation and your preauthorization staff is like, I don't have anything more than what's documented here. And so guess what happens? Services do not get preauthorized. It goes back to the doctor or the provider and more documentation would have to be put into the medical record to support medical necessity. You know, so it does cause a delay in patient care. So please make sure that your documentation supports the need for medical necessity for any of our diagnostic services. So without medical necessity, services won't get paid. And then possibly after an actual payer review, like I was talking about earlier, that some of the payers will hire outside auditors to come in to make sure that they are paying claims appropriately. And so when those auditors come in and they say, oh, you never should have paid these, then there's a possibility of recoupment of previously paid services. And that's hard. Nobody wants to have to pay that money back. So top medical necessity areas of payer focus. And I'm not going to talk about every one of these in detail, but diagnostic EGD, infusion services. I mentioned this earlier, Kristen just mentioned a little bit on that as well. Hemorrhoid treatments, multiple endoscopies, near and biopsy combination, pathology and the need for special stains, screening versus diagnostic colonoscopy, and E&M services. So why do you think screening versus diagnostic so much? Remember that payers are mandated if they have policies that follow the Affordable Care Act to pay that claim in full without patient responsibility. So what do you think they're trying to do? Figure out whether or not they need to pay that claim in full. All right. So again, that's another reason why they look at things a little bit more closely. So let's talk about medical necessity for E&M. I'm not going to go into the detail that Kristen did. So diagnosis codes, and she was just talking about them. The diagnosis codes can trigger a payer down code of the level of service. So for an example, an established patient visit with the diagnosis of GERD was submitted as 99214, but other diagnoses were actually addressed and not submitted and linked on the claim. So if you receive multiple down-coded claims, this can actually trigger an audit. And if one provider in the group is an outlier, this also can lead to an audit for the entire practice. One of my practices had stated that they got into a situation where one of the payers had down-coded claims, and it was based on the diagnosis codes or the lack of diagnosis codes submitted on the claim. And so some of the payers do have a kind of a medical necessity system set into play based upon the diagnosis codes that you submit or the lack of specificity in the diagnosis code that you submit that will trigger a down code just by diagnosis codes. And so one of the things that when we process a claim payment, and a lot of times these are electronic claims, and so what happens is that information is automatically sent into the system, and somebody is going to have to actually manually look to make sure that the claims were paid appropriately. So again, you know, sometimes we get so excited about what got paid, but if you're not looking directly to make sure that the approved amount or the level of service was the same as you billed, it looks like they paid the claim, but they may not have paid it correctly. Patients should pay a close attention to the core elements. So the HPI, compare the diagnosis code submitted against the chief complaint, and then make sure that the provider uses medical decision-making to support your level of service. Often the provider does not fully document everything done in the encounter, imagine that. All right. You know, so focus on the impression and plan, and avoid using the pre-populated problem list, only list those conditions that were addressed. If decision-making does not support the level, use time to support your billing. All right, Kristen went over this as far as documentation of time. So let's talk about the general principles of medical record documentation. So first of all, number one, it has to be complete and legible. I think the majority of our payers that we deal with use electronic medical record systems, although right now, we do have a practice that half of the providers are using still handwritten notes, are using an actual just like a form, that's it. And it's not legible, right? So what happens if it's not legible? It's deemed not to exist. The documentation of each patient encounter should include the reason for the encounter, the relevant history, physical exam findings. Remember, we still have to history and exam pertinent to the chief complaint, the assessment, the clinical impression, the plan of care, and the date and legible identity of the observer. So what happens if you're looking at handwritten documentation? We often see it with anesthesia records, where the actual anesthesia record is handwritten as well. You know, we need to actually find out, and we have to get a list from the practice of the actual print and name of the providers with their signature, and potentially any of the initials that they may use, just to make sure that we can recognize who's who. All right, if not documented, the rationale for ordering diagnostic or ancillary services should be easily inferred. We all know if it's not, pre-authorization will not be obtained. 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 guys, that's really the whole purpose of the medical record. It's not for billing. It's for communication of the patient's care between providers. All right, if it's not clear, and all the documentation is not there to show what's been done, what the patient's response to previous treatments are, how can we give good patient care? The CPT and ICD-10 codes reported on the claim should be supported by the documentation in the medical record. Remember this tells a story. When you're submitting a claim to a payer, you're telling the payer what you saw the patient for, and basically, what's the severity, and what do you think it is, right? And then what did you do, and the reason why you did it. I mean, it tells a story. You want to list the diagnoses or conditions in the assessment and plan. I mentioned this earlier, importance of the highest degree of specificity. Be specific as to the location of abdominal pain. Kristen just went over that with you. Location of IBD and anti-manifestations. Be specific as to liver enzymes. That's probably one of the most things that kind of, it's kind of one of my pet peeves, and it has to deal with the fact it's a pet peeve to your providers as well, because it's not easy to find. So when you put in elevated LFTs, most of the time the software system that gives you R94.5, which is wrong, R94.5 is an abnormal radiologic study, all right? It should be specific to the blood study that your doctors are looking at. So transaminases are 74.01. You've got LDH, you've got ALK-Fas, acid-Fas, lipase, amylase, and bilirubin, and they all have different codes, right? So be specific as to which are elevated so that we actually assign the correct diagnoses. Be specific as to differential diagnoses. This supports moderate complexity. Be specific as to which lab tests and diagnostic studies are ordered. All documentation must be signed or it isn't a legal billing document. Oh my gosh. We've done some reviews where we actually see the endoscopy reports, and they're a year old. They're still not signed. So we think, okay, maybe we don't have the final record. So sure enough, we ask about it, they send the notes back to us, and the signature date is a year old. Right? Because they just signed them once we brought them to their attention. The notes have to be signed within a reasonable amount of time. And sometimes it's based upon state guidelines. It's based upon your guidelines in the medical record. So again, it's so important. So actually, should we be billing anything unless it's signed? No. Every visit must have a chief complaint. So what's the provider's role in the assessment and plan? Again, the assessment of the patient should be clear and include any details in the diagnoses. Don't want to count from problem list. When Kristen mentioned this before, and I said it earlier, when comorbidities and risk factors play a role in the provider's medical decision making, the provider should clearly state these risk factors. The plan of care should show an evaluation and treatment of each condition that relates to the ICD-10 code on the claim. Not only should providers show E&M and evaluation and treatment for all conditions, they, and this is really important, they should also not sell themselves short of their hard work. All right. So a lot of times the conditions may be addressed, but they don't make it into the assessment and plan. And if there's a history of colon polyps and the physician orders of surveillance colonoscopy, you know, we want to make sure that when you state history of, the patient no longer has that condition, and then it should be coded with a history of diagnoses. And I think Kristen mentioned this earlier about ulcerative colitis, you know, and Crohn's and a lot of times we see history of. There's no history of, it's still considered an active disease. So just say Crohn's, just say ulcerative colitis. All right. So endoscopy billing tips. You can't bill for multiple polyps and lesions removed by the same technique. All right. If you remove 12 polyps by snare, you got one snare. All right. Modifier 22. And this modifier 22 means it's an unusual procedure, means that tremendous complexity and significant time spent to complete the procedure. All right. So we only want to use 22, not just because you move 12 polyps, but how long did it take you and why did it take you so long? Those have to be addressed in the endoscopy report. You can bill for each technique utilized to different lesions. That stems back to the multiple endoscopy policy. It's been in effect since 1993. You need to make sure to document the location, the size, the appearance and methods used to treat lesions. So again, it's near the sigmoid, biopsy of the transverse colon. You would need to add the 59 or the excess modifier to the bundle code. All right. Make sure to document the instrument used to biopsy. All right. If unsure, billing staff has access to CCI edits or claim scrubbing software. Make sure to look at that to see if a modifier is truly required. Okay. Upper endoscopy. Most of the payers require pre-op for diagnostic EGD. GERD is not acceptable by itself. All right. So it says gastroesophageal reflux symptoms that persist or recur following appropriate trial therapy for two months or more. That is a GI quick measure. All right. And it's a statement. And we see that a lot of time on the indication on the EGD. All right. But that's not telling me what symptoms. So Kristen mentioned earlier, there is no code for gastroesophageal reflux symptoms. Tell me the symptoms. Persistent vomiting of unknown cause, nuance of dyspepsia in individuals 50 years of age or older. Now, the diagnosis code of dyspepsia is K30. And the diagnosis of epigastric pain is R10.13. So I think most of the time when you guys say dyspepsia, you know, if you're looking, this is an age-related statement. All right. If epigastric pain is not, I would recommend that you use epigastric pain over dyspepsia unless you already have scoped the patient, have no explanation for it. And so we're just going to assign dyspepsia. Unexplained dysphagia or dynophagia. Signs or symptoms suggesting structural disease of the upper GI tract. All right. And we've seen just that blanket statement. But you've got to, again, give me the symptoms. Postoperative bariatric surgery with persistent abdominal pain, recent or active GI bleed. Those are all indications. Unexplained anemia due to either blood loss or malabsorption. Not unspecified anemia as to either be you're looking pretty well by D50.0 for the chronic blood loss or D50.9 for iron deficiency. Those are usually the two codes that are always going to be approved. Also for abnormal upper GI or abnormal radiologic studies of the GI tract. Documentation of varices in individuals with portal hypertension or cirrhosis. So important. You know, we see a lot of times on the indication screen for varices, and I'm like, that's it? Why are you screening for varices on somebody? Because they have what? You've got to put down why you are screening for varices. What is the underlying condition? All right. So also to identify upper GI etiology, lower GI symptoms such as diarrhea. So what are you ruling out? You're ruling out celiac? Say it. All right. So again, doing biopsies of normal appearing mucosa. We talked about this in the lower GI tract. If you're doing biopsies of normal appearing mucosa, why are you doing it? And list the symptoms that the patient has, and that's why you're ruling it out. All right. So UGD with biopsy is bundled into any esophageal dilation code unless the biopsy is outside of the area of dilation or the dilation zone. So you need to specify the exact location that was biopsied. If balloon dilation was done, then the biopsy must be a separate area of the esophagus outside of the dilation zone. If savory guidewire dilation was done, it's very difficult to get that biopsy since it encompasses such a large area. So usually the biopsy would have to be in the stomach or the small intestine. Biopsy is also bundled into ERCP codes such as sphincterotomy, stem placement dilation. Again, be specific as to the site and make sure to document why it was done. Double balloon enteroscopy. I know a lot of you do not do this. It is time consuming, very time consuming. So if you're doing the oral approach, you're going to use the standard enteroscopy codes if the ileum is not visualized and you've gotten at least 50 centimeters beyond the pylorus. 44376 if the ileum is visualized, that series. If you're using the anal approach and you're actually doing a diagnostic colonoscopy in addition to this, you can use the colonoscopy code in an unlisted procedure of the small intestine. EMR, I mentioned this earlier. You need to make sure that the term endoscopic mucosal resection is documented in there. Incidental dilation is considered part of an ERCP done due to remaining stones, sludge, and debris. All right. And that's just dragging the balloon down. So in order to bill for the dilation separate, you need to make sure to document there's a strictured or narrowed area and make sure to use and document the method that was used to dilate. You can bill for more than one stent during an ERCP. Right now, the MUE, which means the limit, is two. So automatically, you should be able to get paid for two. Anything more than two is subject to review by the payer. They may or may not pay for the additional stent. It depends upon their policy. Spiglass, which is a cholangioscopy. So this is kind of the scope within a scope. And if it's used during an ERCP, this is an add-on code. All right. But you need to make sure to utilize that term. Cholangiography is just the injection used during ERCP. And it is part of the ERCP code. Non-biliary and or pancreatic duct images during ERCP are separately billable. As long as there's documentation to indicate the endoscopy provider personally interpreted the images, there is a static image kept on file, and there is no conflict with the radiologist also billing for the interpretation. So again, that is up to your doctor and you to determine whether or not this is billable. And if there are images that go to radiology, you need to make sure that the radiologist is not also billing for this. Whoever gets the bill in first gets paid. And obviously, if you get yours in, there's going to be a conflict and potentially an audit situation. You do not want that to happen. I own this out first to make sure that you know who gets to bill this. On banding or treating hemorrhoids, an endoscopy is included in this procedure, and no modifier will bypass the edit. And you see this is all in caps. Control and or prevention of bleeding is bundled into every procedure and can't be billed unless it is a separate site or lesion. If it is a separate site or lesion, it always takes the modifier 59. Control bleeding would always take the 59 modifier because, again, it's part of every procedure that you do. Whether you inject epinephrine, whether you clip it, whether you suture it, et cetera, it's part of it. We already talked about if you're submitting an unlisted code for procedures that don't have a current assigned specific CPT code to dictate a cover letter, and I had examples of that. All right, so some of our pearls of wisdom. Always list symptoms which require diagnostic evaluation and differential diagnoses, all right? And remember that your preauthorization staff rely on the specificity of your documentation. Make sure that all pertinent comorbidities and risk factors are listed in the assessment and plan. Make sure that specific indications are listed on your endoscopy procedure, all right? And it can delay payments and possible recoupments if you do not have that. Make sure that all documentation is completed and signed in a timely fashion. I hope that you guys do have compliance manuals in your practice, and that you have addressed this, that you have a, you know, a mandated time where records need to be signed and completed and enforced, all right? Keep up to date on all payer policies and share with all providers preauthorization billing and coding staff, all right? And remember that your level visit, we talked about this time and time again, is either by decision-making or time. Perform internal and external audits, and don't forget doing the provider training associated with that. And last but not least, if it wasn't documented, it wasn't done. All right, so polling question. The top area for payer focus on medical necessity is E&M leveling, EGD, infusion services, or all of the above. Eighty-four percent of you say all of the above, and you are right. They look at all of it. All right, thanks, guys, for listening.

medical necessity

insurance companies

documentation

auditors

endoscopies

E&M services