And we're going to start with question number one. If the physician performs a colonoscopy with EMR and is very large and flat and very difficult to get it to elevate and he has used biopsy, snare technique, on ablation using APC in order to get the EMR done and it's only one polyp, can you only bill for the EMR? Our physician is not happy that these procedures can sometimes take a while to complete and the reimbursement is so low compared to the time he is involved in doing the procedure. Do other advanced endoscopists have a way of handling these situations? It's kind of back to the EMR issue again, but you're only supposed to be able to bill that EMR because it's all, it's all procedures done to remove that one lesion. Now in rare circumstances, you can append modifier 22 when the work is required that's substantially greater than typically required, but we're back to the procedure time and complexity should be documented within the operative report. Kind of just for those of you and even the providers out there, there's a way to figure out to see what is calculated into the, to the work time and actual procedural time. Typically it's a free download, it's from CMS and it has the typical times associated with each procedure. So that is actually a good area to look at to see what is, what time is factored in to that procedure time on the day of that procedure to determine was this substantially greater than the time that's already built into that. I received conflicting information in regards to Cologuard for positive Cologuard. Is it to be coded as screening and diagnostic? Currently we use probation for documentation, which codes it as diagnostic. Well this goes back to the update to the preventive task force list. And again, we talked about this earlier, you know, went into effect May 31st of 2022 and for Medicare effective January 1st, that if the patient has a positive screening Cologuard, then the patient is allowed to have that preventative benefit. And we would bill the screening colonoscopy with the Z1211 and R19.5. And Medicare came up with that modifier KX to identify this service. Now one sidebar to this, keep in mind that for the patient to qualify for Cologuard, they must be average risk, not high risk. This has kind of come up with several practices and actually we've had quite a few questions on it on our support line as well, is that what happens to the Cologuard for the patients that have a history of polyps? Well, when you go on the Cologuard guidelines, I mean, whether you read the commercial, whether you go online to Cologuard, it's only indicated for average risk screening. So if the patient has been given the Cologuard for other than average risk screening, then a positive Cologuard would be considered a diagnostic colonoscopy. So question number three, we have a patient that had an EGD with a PEG tube change done by two providers in our office. One provider did the EGD procedure while the other did the PEG tube part of it. Are we able to bill for the procedure with both procedures or to bill both procedures? If so, do we do that with the modifier? And the question kind of got, when you read through it, it's a little bit more, it wasn't an easy one to kind of look at, but what the guidelines are is this is actually approved for modifier 62. So endoscopic PEG placement 43246 is approved for modifier 62 and it applies when providers from separate specialties work together to perform components of one procedure. Now when you look at the definition of modifier 62, it says two surgeons usually from different specialties work together on one reportable procedure. So two GIs may not qualify for this and a lot of times when the payer sees claims coming from the same specialty group, they pay one, pen the other, or they may actually pen both and they want to see documentation. So some of them strictly follow guidelines that say, hey, there has to be two separate specialties in order for these to be paid, but documentation should be in the reports as to why two surgeons were required within the same specialty to work together on one reportable procedure. Now co-surgeons require, the policy for co-surgeons is each surgeon must have their own report, all right, procedure note, endoscopy report, and each describes their part of the procedure. And on that report, it should say surgeon and surgeon are co-surgeon and co-surgeon. The patient was there for colonoscopy. There is a polyp in the sigmoid colon and it is removed by snare polypectomy, but it's not retrieved. So there's no path and nothing else was done. Would you use just 45378 or would you use 45385? Well, you did the procedure. You removed it by snare. So you can still bill for the 45385. Now as far as the diagnosis code, since you did not have anything to submit as path, you would just bill the K63.5 code for the colon polyp. So since there's nothing to confirm whether the lesion was neoplastic. Number five, we have been getting denials from UnitedHealthcare and Cigna when the authorization that we have doesn't match the procedure that was done. Is this something that others are seeing? And is this the best practice to authorize every CPT code in the EGD family or colonoscopy family since we cannot predict the outcome? Unfortunately, yeah. Specifically UHC has been doing this for a long, long time that if you did not get something preauthorized at the time, then technically they say that they're not going to cover it. So yeah, that's a long laundry list, especially when you're looking at EGDs. The amount of EGD procedures are almost triple that of what the amount for colonoscopies are. Now for Cigna, this actually was a recent development after in the past year and a half. So recommendation would be to at least go for the most common things that you may see. As far as screening goes, I think definitely SNARE, biopsy should definitely be preauthorized. You could only even go farther than that. Question number six, we would like to know which diagnosis code is more appropriate for an abnormal liver function blood test. In the past, we used R74.8, but should we be using R94.5? I actually kind of answered this one earlier. So when you're looking at the R94.5 code, it's for abnormal liver function studies when you look into the index, but it's actually the heading of radiology. So abnormal blood liver function tests actually need more specificity. So ALT and AST is R74.01, LDH is R74.02, amylase lipase and ALFAS is R74.8, bilirubin is R79.89. So really your providers need to specify the specific enzymes elevated. If they don't, then we're really stuck with R74.9, which is an unspecified diagnosis code. Number seven, we have recently had a RAC review in regard to infusion billing. We have a request for recoupment since incident two requirements were not met. There was always a provider onsite, and this was documented in the records, and we billed under the provider onsite. Why did we get this request? All right, so that's a good question because sometimes you cannot figure out why. The first step is anything with a recovery audit contractor, especially if you see that it's coming from the RAC, you want to recommend that you contact a health attorney right up front. If you haven't already done so. All right, also, and I mentioned this earlier, I would recommend that you look at box 17 on the 1500 form to see who's listed as the referring provider. This should be the referring provider or the ordering provider in your practice. If this is an external provider, that potentially could be your problem because the infusion order must be initiated by your internal provider. There are several things that you can get pulled into a RAC review, and sometimes you really don't understand because they're looking at your records, and specifically if they say you did not meet incident two requirements, that probably, this issue right there is number one. I also meant, too, that if you didn't have the requirements documented or your proper documentation requirements, you would have gotten a different reason for that. Again, when you get everything, a request for records, making sure that you send your infusion note, you send everything related to that, the current order, when the patient had their TB test, their hepatitis vaccines, et cetera, anything that would apply to this encounter. All right, so we want to try not to leave anything out that would cause a further review. Number eight, this kind of goes back to the EMR again, and again, these are kind of the heading for this is the top coding questions that we see through ASGE, and a lot of them have to deal with the EMR. So what kind of documentation? We are having difficulty distinguish the difference between a lift and snare polypectomy, 45385 and 45381, and injection-assisted EMR, 45390. 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-penunculated at a different location in the sigma colon of 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 hot and cold snare polypectomy. The base of the polyp was fulgurated at the tip and with the tip of the snare. Three hemoclips were applied at the site. The site was tattooed using India ink injected in the opposite wall of the polyp. All right, now, your physician's documentation would support assigning 45390, and according to the primer, includes a semi-calcil injection, the banding special device to remove the tissue. The EMR technique is applied. The cap can be used in combination with the banding. Hemostasis may be required, and since this is much more involved than a simple saline lift and snare, payers will often request records simply before a payment was made to make sure that the EMR was actually performed, and again, kind of back to that demarcation issue. You know, it wasn't, you know, the semi-calcil injection to demarcate that lesion, all right? It really was not exactly clear in there that the area was demarcated. So endoscopic ultrasound may be separately billable, and that's another thing that sometimes we do in EUS at the same time, and to make sure that the term EMR is used in the endoscopy report. I billed an unlisted code for a fistula closer, and Medicare's denying my unlisted code is unprocessable. I did not notate anything in Box 19. This is my second time using an unlisted code. I am not too familiar with them. Would I appeal on the Medicare portal with documentation? Well, when you bill an unlisted code, Box 19 must be filled in, or it is considered unprocessable as stated on your EOB, and it's true. That does mean that you have no appeal rights. So what you have to do is an error logging adjustment on your system and start over again, but this time you're going to put endoscopic fistula closure in Box 19. Now remember, your EOB will still not give you the automatic payment, but it will prompt you to send documentation at that time. Like I said earlier, we're not going to send the information at the time of the claim submission. Only after it's processed and it comes back will you send the information at that time. Now that's to Medicare. Some of the commercial payers may tell you differently, and it all depends on their guidelines. Sometimes they may actually want additional documentation sent by email, even by snail mail, et cetera, but sometimes you can submit it at the time of initial claim submission, but most of the time, no. You want to at least process it electronically so that you get something back that shows it that it was filed in a timely fashion, and then you follow through. Number 10, one of our doctors sent this to me last night. Are we able to bill the 74328 to 74330 codes when we do an ERCP if the radiologists are not billing and reviewing these? Just looked in an ERCP report from an academic center. The endoscopist made a notation that he personally interpreted the file duct images. The wording made it sound like a billing-directed statement. Do we have any idea if we were able to bill for imaging interpretation during ERCPs, and each one of us interprets the images in real time? So, if the documentation supports that the provider personally interpreted the images and provides detail, you can report 74328 to 74330 with modifier 26. So the 328 is for the bile duct imaging. The 329 is for pancreatic duct, and 74330 is combined both ducts. All right, so make sure that there wouldn't be any complication with the, or conflict with radiologists. I had mentioned that earlier, and only one provider is allowed payment. So the guidelines, and this was published back in 1996, CMS pretty well stated that the provider whose interpretation guides the further care and treatment by the patient should be the provider that submits the charge. I think for those of you listening in today, you're not waiting for the radiologist report before taking the patient home from under anesthesia. Your interpretation, when you do the contrast, and it shows whether or not that there is a free flow, that you got all the debris, all the stones, et cetera, that the stent was placed and everything's patent in particular, you're the one that pretty well guides the further care and treatment of the patient. So it does support that you should be able to bill for this service. However, we all know that potentially the radiologist will also submit a charge if they also got the images and they interpreted them as well. So I made this, I mentioned this earlier, before you start billing for this, all right, you do want to double check. Since most of the time these are done in the hospital setting, you want to check to see if there is a cholangiogram report or an ERCP report, and there will be, because remember that the hospital bills for technician time, for the technical component of these codes. And usually on that report, it'll show that technician time, 10 minutes, 20 minutes, et cetera, and most likely it'll say see endoscopy report for full interpretation. If you see something like that, then you know it's yours to bill. But if it also gives you an interpretation that shows the duct size was this, this, and that, then you know the radiologist has read it and most likely they are going to submit the charge. So again, this is something that should be discussed between your physicians and the radiologist, just to determine who gets it. All right.

coding and billing

colonoscopy with EMR

modifier 22

Cologuard test

multiple providers in office setting