All right, overview, so things, some things that we're going to discuss, why are our claims being denied? How much does the denial cost your practice? And I know that Kathy had kind of mentioned this earlier in the day. Understanding what an EOB is, explanation of benefits. Okay, that's what that's the information we get back from a payer that is information of how they processed our claim. And then we're going to look at what are they looking at? Top denials for GI, okay? So claims that often get routinely denied for us. So why are our claims being denied? Many medical practices are seeing their AR climbing and cash flowing declining. With the implementation of electronic records, claim scrubbers, electronic claim submission, some were under the impression that the process of submitting claims and getting paid quicker was going to be so much easier. Although they have proven to be beneficial, claims passed through the scrubbers and clearinghouses but are still being denied at the payer level, delaying your payment and costing you money. Not all denial reasons will be caught when passed through the claim scrubber or electronic billing. Sometimes the cost of trying to get a denied claim paid is more than the actual reimbursement, which is why it is so, so, so important to prevent claim denials and submit initial claims clean. We want to get them out clean the first time around so we don't have to mess with them on the back end. Because again, the more we have to call and figure out what the heck the denial is, and then you're on the phone with the insurance company for an hour and a half, and then you finally get someone and they say, oh, we're not allowed to tell you that, we can't give you that information. It's like, okay. So then you've done wasted, again, two hours and no what? No correction. Still the same outcome. So how much are denials costing you? Recent studies show it costs an average of $6.50 to file a claim. The cost to resubmit, $25 to $118. The cost to submit correct and resubmit, $31.50 to $124.50 per claim. While most claims can be corrected and resubmitted for reprocessing for payment, some claims submitted and denied are legitimately not payable and are preventable from ever entering the cycle and needlessly costing your organization money. So we've kind of been talking about this all day, okay? Don't put screening and symptoms, don't submit a claim where the diagnosis that's primary is not allowed to be primary, or you can't build this diagnosis with this diagnosis. All those little bitty things add up to where I can fix it on the front end before it even goes through that denial cycle. What is an EOB? Explanation of benefits, okay? Commonly attached to a check, hopefully, or statement of electronic payment, and typically describes the payee, the payer, and the patient. So what did you perform, okay? The date of service, the name or place of the person providing the service, and the name of the patient. The doctor's fee, so what you charged, and then versus what the insurance allowed, the amount initially claimed by the doctor or hospital minus any reductions applied by the insurance company. The amount the patient is responsible, and then again, adjustment reasons, adjustment codes, that's kind of where your denials codes come in. Like Kathy said, I've seen EOBs that have seven denial reasons, and I'm like, oh my gosh, where do we start? So and some of those, again, you may not get the answer, and you might fix four of them and still can't figure out the other ones. So sometimes they can be a little cumbersome. Not denial reasons for GI, or excess, all right? So we're talking about bundling issues. So you might get a remark back, bundling or procedure code incidental to the primary procedure, things like that. Be sure your staff is educated on how to use the correct coding initiative edits. Once those edits are in place, they are available to all of us online, it gives you the ability to see, okay, my provider performed these two different techniques in this procedure. Number one, can I bill both if it meets the requirement? And number two, is a modifier, 59 or excess, appropriate? And number three, which CPT code does that modifier go on? That's where the CCI edits come into place, and that's where they it explains all of that to you. All right, well, guess what? Our big one, our biggest one, our biggest bundling denial is your snare and your biopsy. And payers know this, and payers routinely request documentation when you bill a snare and a biopsy, okay? So number one, before we even think about submitting these two, you got to make sure they're on two separate lesions treated by two separate techniques, okay? So I did a snare of a three millimeter polyp in the ascending, and then I did a biopsy of a two millimeter polyp in the transverse, okay? Two separate polyps, two separate techniques. Providers must be clear in their documentation on location of the lesions and methods of removal. I was looking at an endoscopy report the other day, and it said this patient had six different polyps, all right? And then they even listed out every single polyp size, but then they said, all removed by ablation, snare, and biopsy. That is an issue. I can't, I can only bill, in that scenario I just gave you, I can only bill the most extensive, which is the ablation. Because I don't know if you did those techniques to every polyp, or you did ablation here, biopsy here, snare here. I have to know exactly, I always say size, location, method of removal on every single lesion you encounter. So you've got to be clear. Utilize your diagnosis pointers on the claim to indicate diagnosis one is specific to this one, diagnosis two is specific to that one, when we can. Watch your dilation and biopsy. That is another, this is upper endoscopy, that's another highly reviewed or appended claim, is especially when you only have esophageal diagnosis codes on that claim, okay? So these got bundled in 2018. And we can unbundle them, so as long as the biopsy is outside of the dilation zone, okay? If it is outside, if the biopsy is outside the dilation zone, you can bill the biopsy with a modifier 59 or excess. There should be a completely separate diagnosis for the biopsy. So here's an example. A stricture was found in the esophagus, which was dilated by balloon, and an area of chronic gastritis was found in the stomach, which was biopsied by cold forceps. Those are completely different areas. So we're good. But when I bill this out, I'm going to bill the dilation in the primary position because that's the most extensive procedure. The diagnosis I'm going to point to is for the dilation, the stricture. And then the biopsy on the second line with your modifier, and that one is going to point to the gastritis because that's what I biopsied, okay? So you're telling the payer a story. The claim is telling the payer a story of the services that were done on their beneficiary, okay? So when we use the diagnosis pointers, we utilize box 19 for comments, free text, that is a less likely chance that we will be denied, okay? Not saying all the time, but maybe less than our denials a little bit. One more thing about dilations, all right? So hard to justify. I'm okay to justify, let's say, a balloon dilation in the mid esophagus and a biopsy in the distal esophagus to rule out EOE. Those are separate because they're separate areas in the esophagus, separate areas, if I'm clear in my documentation. But what about guidewire? So guidewire may typically dilate the entire esophagus. So if you are doing guidewire dilation and you're billing biopsy separately, most likely, hopefully, that biopsy is probably in the stomach or duodenum. It's just somewhere completely different. One thing that I want to comment on about the biopsy, okay? Especially on the lower side. I think we see this more of an issue on the lowers than the uppers. We see sometimes we're not documenting the method of biopsy, so we need to document the cold forcep biopsies. Remember guys, there's more than one biopsy out there. And your payer, remember, doesn't know, they don't walk next to you and see what you do every day. They are looking at the CPT code that you billed, the description of that code, and they look at your documentation to match and see if it matches. And if it's not clear, they're not going to pay you for the biopsy. So cold forceps, there's hot biopsy, there's brush biopsies. Those are all three different CPT codes, so you've got to be specific. If the payer is still, nope, we stand by our original decision, even though you sent us records and it definitely supports separate sites, separate techniques, separate methods, whatever, then you need to send them the CCI policy that specifically states 45385 with column 2 45380 is often bypassed with using modifier 59 or the X modifiers. Use of modifier 59 or XS is only appropriate if the two procedures are performed on separate lesions. Use of modifier 59 and XC or XC is only appropriate for two procedures performed at separate encounters. Okay, so that's kind of your ammo there. Couple of examples, you've got colonoscopy with biopsies of the rectum and snare polypectomy of a sigmoid colon. So we're going to bill the snare primary and the biopsy secondary with the modifier. Another one, this is actually a control a bleed situation. EGD with biopsy of gastritis in the stomach and application of bleeding duodenal ulcer. Modifier 59 or XS would be assigned to the bundled code. So remember guys, when you're billing multiple procedures, control a bleed is always bundled. You have to unbundle it. You're telling the payer, hey, I didn't cause the bleeding. I'm preventing a bleed, but I biopsied a separate area. Number three, ERCP with placement of stent into the right hepatic duct and another into the pancreatic duct. Okay, you can bill for multiple stent placements, but you have to modify that second one. And then again, utilize your comments to document where the location of the stents were. Question, what services can you bill when a patient comes to the office for a pre-scheduled hemorrhoid banding? An E&M visit, the banding procedure, an E&M visit and banding procedure, or nothing. You should be providing free services. Oh, good job, audience. Correct. Just the banding. Just the banding, which segues into my next topic. Modifier 25. All right, so modifier 25, I'm going to tell you that's probably one of the most highly audited modifiers right now. We even have payers that actually have in their updated policies that if you try to bill a follow-up visit with the 25 modifier and a procedure or other service on that same day, be ready to get your documentation reviewed. Doesn't mean you're doing it wrong. They're just making sure that they're not paying you for something that doesn't meet the requirement. So modifier 25. This is submitted on a visit the same day as a procedure. Again, other service. Infusions, could be a fiber scan done that day, capsule, endoscopy, whatever it is. It's something else done. So 25, you're saying, hey, I didn't just peek my head in the door and say hi and then do the procedure. I made the decision to do it. Something else came up that I addressed. So that's modifier 25. And guys, this is all in your documentation. We get a lot of questions that say, if my doctor does a visit and a procedure on the same day and he decides to do that procedure, can I bill that visit with the 25? Most likely, yes, but it's never a 100% yes until I see your documentation. I have to see it. I have to make sure that there's recommendations made. There's a note that exists out there. So again, this is very highly audited. So significant separate visit is billed on the same day. Nothing is pre-scheduled. So just like that polling question, if I am here for my banding, that's all I should be billed for. Unless the patient's like, oh, by the way, doctor, in the last couple of weeks since I've seen you, I started having this horrible heartburn and chest pain. I can't sleep at night. I cough. Like, OK, yes, let's address this. Let's give you a prescription. If that doesn't work, we'll set you up for an EGD. That's different. But the diagnosis on that visit is going to be reflux, chest pain. It's not going to be hemorrhoid or rectal bleeding. This is not a quick meet-me-in-endo. Again, or sticking your head in the door after the patient's had their procedure done saying, hey, how you doing? You doing good? OK, see you in six months. Not billable. Hospital follow-ups. If you round on a patient and they're scheduled for an endoscopy in the hospital, that follow-up visit is not billable unless what? Other things are addressed. Something significant, something else that has nothing to do with what you scope the patient for that same day. Diagnosis order on the claim can be essential. So let's say you do a consult for GI bleed, rectal bleeding, or GI bleed, anemia, et cetera. And you're like, we need to take the patient to endo immediately. You take the patient to endo. You find a gastric ulcer. You treat that ulcer. You can put anemia for the consult and then the ulcer for the procedure, as long as your diagnosis codes don't get bumped out against each other like we talked about earlier. But diagnosis codes can be essential. So a couple of examples. Patient presents to clinic for planned infusion. The patient also had a separate six-month evaluation with her GI provider. The GI provider documented the status of her ulcerative colitis, ordered routine labs, and addressed the patient's reflux disease. That is definitely significant, significantly separate. So I would put a 25 modifier on that visit. Here's another example. Patient is seen in the hospital as an initial visit for evaluation of feeding difficulties. Provider performs a separate history exam and decides the patient would benefit from a PEG-2 placement as well as management of nutritional deficiencies. So again, wasn't pre-scheduled. I had to ultimately evaluate the patient to make sure, yes, they are good to go with the PEG-2. So I can build that visit as well with a 25. Another area, place of service. Okay, so we talked a little bit about this when we were talking about E&M services, observation versus inpatient, things like that. So make sure you build the correct place of service in which the patient received the service. We recommend holding your observation charges. Oftentimes, the patient's hospital stay changes to inpatient, which is a different place of service. Now, guys, remember, you're still gonna report most likely the same CPT code given those changes, but when we ask the billing department to hold those claims, we're doing it for a reason. If that stay ends up being transferred as an inpatient from the time your doctor sees the patient till the time I'm billing that claim out, and I still billed place of service 22 because I think their observation still, guess what's gonna happen? I'm gonna get a denial, and the denial's correct. We have to match the hospital's designation for place of service. Gotta watch that. All right, so again, we had that question earlier today and I kind of answered it, but I said I'm gonna dig a little deeper into that and that this talk, this is what I'm talking about. So then we got all these new changes for our hospital observation CPT code. So now everybody's like, oh my gosh, well, what happens if I'm the consultant and the patient's an observation? What do I bill? So Novitas is a Medicare contractor out there. This came out January 19th of 23. So for services on or after January 1st, observation services are billed by the admitting physician using the initial inpatient or observation care codes. Then there's subsequent care codes, and then they can also potentially bill the admit and discharge on the same day codes if that meets the criteria, and then the discharge services. That's what your admitting physician could potentially bill. All other physicians billing. Observation care codes are billed only by the admitting physician. All other practitioners providing care to patients receiving observation services bill office and other outpatient codes 99202 through 205 or 211 through 215. New versus established patient rules apply, okay? Observation care is an outpatient service. Although the code range includes inpatient and outpatient services, the place of service code should identify the patient's location for the services billed. All claims for observation care are billed in place of service 22. So I kind of answered that already earlier today, but the unfortunate thing about this, if you're one of your patients gets admitted to observation and they stay in observation and you are asked to do a consult, you're stuck with established office visit codes, okay? Again, I'm just the messenger. Didn't make up these rules. UnitedHealthcare, same thing, okay? They've got the same policy, and we've got their, they say only admitting provider can bill the initial hospital to observation status. All other providers, 202 through 215. Haven't heard anything from Anthem yet. We've got some other Medicare contractors that have observation fact sheets, but they were prior to the changes, okay? So keep up on payer policy. Medical necessity, and I think Kathy's gonna go more into medical necessity, but that's one of the biggest denials we get is medical necessity, okay? You gotta make sure you know what the payer approves, what they're gonna preauthorize. We have a lot of services that require preauthorization, especially our upper endoscopies. So you gotta know what the requirements are. We still have payers that consider capsules experimental and won't pay for them. And there's very, very limited coverage on those, okay? So our documentation has to support why we're ordering things, and it makes the preauthorization a lot smoother, and we will likely get paid for that service. Diagnosis, make sure the primary diagnosis submitted on the claim is specific and is supported in the medical record. And document your comorbidities and risk factors. Endoscopic indications have to be very specific, okay? And don't ever leave them blank because then that's not billable. Infusion services. So if you've got an infusion department, you've got nurses that are infusing the patient, they're the ones documenting the infusion. Do they know the importance of being specific? Many payers are denying infusion claims for medical necessity when a nonspecific IBD diagnosis is billed. Honestly, that makes sense. If you have a patient that has ulcerative colitis or Crohn's and you're doing an infusion on them, you probably should know what they have. So we gotta be specific. That second bullet, R10.9, do not use that diagnosis code. Not primary, not as a GI provider, okay? One of the biggest things, one of the biggest comments from providers that we get, I can't find it. So they type in abdominal pain and here comes 20 different diagnosis codes and you're already behind in clinic, you still gotta scope people and you still gotta go to the hospital. So a lot of providers are not gonna just drill down to find that specific location. Guys, get it on your list of favorites. If the patient just says, oh, the pain's everywhere, there's not really a quadrant, pick generalized abdominal pain. That is better than I don't know. Anemia, don't be ordering procedures for anemia unspecified. Okay, it's usually gotta be an iron deficiency anemia and make sure you have supporting labs in your chart to support it. Unacceptable primary diagnosis is another one. We already talked about that, okay? So some of our payers are more picky than others. So again, if I try to bill Z86.010, I get a denial back saying that's not a primary diagnosis. They want that followup listed first, the Z08, Z09. Same with secondary varices, that's never gonna be primary. You've gotta put the cause first. Your excludes one, that whole list I gave you. And that's not all of them, definitely not all of them. Those are just our most popular ones. So again, if you get a denial back that says these two codes can't be reported together or invalid diagnosis coding, look to make sure those two codes can be billed together. And we've got, gave you the list in these slides as well. Remarks, never assume a denial is due to a coding error. Always research the reasons on the EOB. Never write off the claim with the first denial unless there truly was an error in submission. Research and resubmit. Never accept the payer's initial review. Go further, usually upon review and a fair hearing. By the medical director, the initial denial will be overturned and the claim will get paid. Be a thorn in their side. If you're not a thorn in their side and you're not following up on your denials, they win and they get to keep your money. Utilize your medical necessity tools and involve your patients in the appeal process. And that's it.

medical claims denial

cost of denied claims

preventing claim denials

Explanation of Benefits (EOB)

gastrointestinal claims denial

denial appeal