So, we did get a couple of questions in advance. We already answered one of them, but the first of the other two was, can both 45385-45380 be correctly posted for the same location? And they mentioned transverse in particular. Are there possible issues with denials with commercial or Medicare insurances in regards to reimbursement? So, the person goes on to say, specifically, a 3-millimeter transverse polyp removed by cold snare, a 9-millimeter transverse polyp removed by cold biopsy. Okay, so, this actually goes to CCI policy, and you'll find this in Chapter 6, Section G, or Section H, Number 25, and where it specifically says, as long as they're separate lesions removed with separate techniques, each one is separately billable. So, this is where your modifier on 45380 comes into play because it is bundled into the snare. And it goes on to say that you would use a 59 or the excess modifier. So, yes, you should be able to get paid on both of those if you have a payment. And this is actually the most common denial we see, is between the snare and the biopsy. So, we want to utilize that policy, and I'll say that again. It's CCI policy, Chapter 6, Section H, Number 25. All right, you can look it up. It's very easy to find. But that is ammunition for your coding staff and your billing staff to utilize when you're dealing with the commercial payers, as well as Medicare. All right, but yes, it should be separately reimbursable. Okay, so I have someone here who presents a scenario, and then they have some questions. It's a bit long. So, what they write is, some of our providers document screening and history of colonic problems, so Z1211 and 86010. Due to previously reported information that this can be done per plans, we have mostly seen this with UnitedHealthcare, Humana, and Blue Cross Blue Shield commercial carriers that they will cover under preventative benefits at a sooner interval, such as one year, three year, and five year. In order to bill this way, it has been recommended to have a written policy in place with these carriers for auditing purposes. So, this person goes on to say, my question, what is really the best practice? If a patient is coming in for a history of colonic polyps, as the indication, this should be the only diagnosis to add to the claim if CPT is 45378 is performed, correct? Patients are upset because they're confused why Z86010 is not considered under preventative guidelines. This can put potential high-risk patients under great stress, as they will have to determine paying out-of-pocket costs or extending or not even coming back in for the recommended recall. Did you get all that? Yep, and it kind of addresses during the screening versus diagnostic presentation. I mentioned that when you go and look at the policy, and I even had UnitedHealthcare policy up there, that they won't cover history of polyps at a preventative benefit. Now, I did say that there are exclusions to this simply because the individual patient plans or employer plans can supersede this policy and allow for the, for those patients to have that benefit, even with the history of polyps. So again, if that's the case, I recommend that you do get something as written policy to support your billing for this based upon that particular payer policy. Now, as far as Humana and Blue Cross and Blue Shield, Humana's policy also online follows United, and Blue Cross and Blue Shield payers, again, individual employer policies can deviate from the national policy. So recommendation is to make sure the patients up front at the time of scheduling know what the benefits are and what their potential responsibilities are. And yeah, it does put them at great stress. You know, this is a financial issue. I think we know that when you look at co-pays and deductibles for patients, you know, it's not a simple $500 co-pay anymore. You know, we've got co-pays $5,000, $10,000, $20,000. So you know, yes, and that can definitely restrict them from following through on their recall status. So unfortunately, we do have to worry how we bill these. If we don't follow the guidelines by the payers, and we kind of, let's get a little creative with the coding on this, we can put our practice at risk as well. Our next question. Thank you for that, Kathy. Our next question is, we do billing for both ASC and physician, and EGD with biopsy performed due to a finding of gastritis and a Bravo is placed. Would the billing look like this? Date of service, hyphen, ASC claim with 43239 and 91035-TC, physician claim 43239.96, hours later, day of interpretation, physician claim 91035-26. Or what else could it be? And that's right in the Q&A if you want to look at that. Okay. So technically on the ASC claim is correct. The physician claim would be 43239, all right, on that same date of service. Now as far as the 91035 goes with the 26 modifier, yeah, that would be appropriate on the day of interpretation. All right. All right. Now the place of service is what can deviate just a little bit, and it depends upon the payers. All right. So for Medicare purposes, the place of service would go back to where the place it would be actually place of service 24. All right. For the commercial side, most likely it's going to be place of service 11. Again. All right. Kristen is shaking her head, Dr. Lindenberg, so you've got agreement there from all the experts. So our next question is when coding for family history of polyps, we have to code, sorry, something jumped on me. We have to code to the last digit, but some payers do not accept the 83719. But what can we use instead as patients do not know what type of polyps their family has? Yeah, I knew that was maybe going to be an issue. So I guess do not accept it, meaning is it coming across as an invalid diagnosis and their system's not updated, or are they not covering it as a high-risk diagnosis, which is a potential issue? We've had, it came through the support line this week, too, that there was a denial from one of the payers on that, all right, as a not covered diagnosis. So lacks medical necessity. So I have a feeling that they haven't updated their systems just yet. Yeah. I had a question the other night from one of the doctors, and he said, well, what if I just put that the patient said that they had a family history of adenomatous polyps? And I'm like, if you put it down, then I'm going to use it, all right? So but that's up to you. That's up to you anyway. Our next question is, for unlisted procedure, can I use a closely related CPT with comparable RVUs? And they also ask, also, if there's no close CPT, what's the appropriate way to bill unlisted procedure? Okay. So most of the time, there's not really closely related endoscopic procedures for what we do in the advanced endoscopy side. So the best way to do it is to look into the open or laparoscopic approaches to see if there's something, or even if you're doing it from the anal approach, there are some transanal codes in there, erectovaginal codes for fistulas, et cetera. And you can use these to determine the, or to set up your fee schedule for those. You know, that's the best thing that you're going to do. Remember, these are going to end up having to take, you know, they're going to not be automatically paid anyway. Any unlisted procedure code is going to go into a review situation. And that's when that cover letter that I showed you before, you know, your docs and your providers really need to set it up. And this is what we were basing it on because the work is there. It's just the approach is different. CPT guidance is very clear. You should not use a code that's somewhat analogous or somewhat similar. Seems like the closest thing. If it's really not the actual descriptor of what you've done, then in many cases, you need to use unlisted codes and with the techniques that were reviewed earlier today. So, there are many codes, as you know, you've seen in the course of today that don't have CPT-1 codes and probably won't for some time. There are a whole lot of reasons behind it. We're looking at where we can move forward with new code applications, but there's a lot of pushback from other societies who, you know, claim these are not ready for prime time and I want to push for Category 3 designation, which usually means no payment and then you're in kind of a billing dilemma. And so, we're trying to work our way through this quagmire and, you know, little by little get more of our advanced procedures, both coded and paid for appropriately. So, there's just lots of issues between here and there. So, we have a question here that I would like to respond to. So, our next question is, on these polling questions, are you going to be sharing the correct answers so I can share them with the providers? I love this. It sounds like you're going to quiz your providers. That sounds fantastic. So, we will have the recordings. So, you have access to GILeap and that's where you're going to complete the eval form and get your CME, which you can convert as you need to if you are not a position, but you'll also get the recordings from all of these lectures today. So, the correct answers will be highlighted in the recordings, but we as staff can look at just creating a document, working with our presenters, and making sure maybe you could just have a little, you know, it'll be like two pages with the polling questions with the correct answers highlighted. And then, yes, you can... Dr. Littenberg is shaking his head. He's like, yeah, let's quiz them, quiz those providers. So, we will get that prepared for you all and just... So, look into GILeap. You'll have access to these recordings for three years. So, that's the life of these programs. Of course, this is just for 2024, but these recordings are very useful and we hope you'll go back into GILeap and get those materials. Our next question is, can you bill under a position if the entire medical decision-making is performed by MD? Attestation is not extensive, but states that you did the medical decision-making. Not sure if that's a clear question. Are we clear on that? I'm thinking maybe they do a little bit of a decision-making and then say I did it all. I'm not sure. I mean, there needs to be two of the three, right? Complexity of problems, data, and risk. So, I would assume the documentation, that addendum needs to support that you at least did two of those three components of decision-making, if that's the question. Yeah, thank you for that. And if we didn't get that answer or if we're not hitting the mark there, you just retype in your question for us. So, thank you, Kristen, for that. Why does denial cost so much? Can you explain to the physician perspective? Because we never see that part. I don't know, it's just, you know, it's the statistical, it's just the cost of if you've got an employee, you've got a claim that you bill out that you don't get paid for and you've got an employee sitting there that you're paying to work the claim and find out and resubmit. And that is material and it costs, you know, just comes off the top, the top, the top, the top. So, I think that's what it is, really. And because every time that you submit a claim, the clearinghouse charges you a fee for this as well. And sometimes you can't figure it out and then you get on the phone and you're on hold for 30 minutes, 45 minutes, and then you get cut off and you have to start again. No, and it's very time consuming, you know, and then Kristen, you kind of had that broken down before in your presentation, you know, and the thing is, is then you finally get to talk to somebody and they can't tell you. So, I don't know, we can't give you that information. Or if we do, we'll have to kill you, one of the two. So, you know. Okay. That's kind of why the cost, you know, can build up. It's a lot of overhead that is built into this. And that's why we'd like to get, you know, we like to send out a clean claim, you know, make sure that everything, the I's are dotted and T's are crossed and appropriate modifiers are signed, you know, so we don't get denied. Then there are issues like you get the wrong insurance information from the patient or else it's transcribed into your system wrong, and then you're chasing down the patient, you're trying to get a current insurance card. There are issues of what's primary and what's secondary when people have two insurances and often the companies will fight each other and pretend that neither of them are responsible or you have weird situations where there's work comp or disability and then you're dealing with multiple carriers. So, a lot of these things wind up with unusual situations with a lot of phone calls waiting on hold, things of that nature. It's not simply that you just redo the claim in your system and send it in electronically and it's done. That's the minority in these situations. And our next question is, if the carrier is UnitedHealthcare and only the admitting provider can bill 99222-inpatienthospital, if our provider, who's an NP, sees the patient established to our practice as a split share and we are to use 99213-99215, how would that work with an FS modifier? So I think this is more so maybe the admitting providers billing 99222, maybe the patients in observation status. So observation place of service should clear with the FS modifier. If not, so not all payers except FS modifier, all right? That was more of a Medicare CMS-driven modifier, so, you know, that might be the issue. I'm not sure what a good answer is on that one. I don't think this is a problem for the inpatient status. Yeah. This is more of your observation. Give me anecdotes. I tell them, you know, send me billing. Let me look at this. And I never get it. So I've never actually seen one where it's inpatient status, but it's been a problem. I think the private carriers follow Medicare that you can use the initial admit codes when you're a consultant if they don't accept consultation codes. So I think it's an observation status issue. And again, the advice was wait a few days, you know, see if they stay observation or, you know, either get discharged or get turned into actual inpatient. And then you can use inpatient if that's where they wind up. Shouldn't be a problem. So. Yeah, and that's kind of the sidebar on this one. You know, when we get charges back from the hospital from the providers, you know, don't be in such a rush to submit those charges because we don't know what the status is going to be on that patient. So they might have been admitted to observation, but they're there for Medicare. It's a two midnight rule. So if the patient stays over two midnights and technically they become an inpatient status, so then that would charge change to an inpatient situation. But then we get these weird commercial payers out there that keep people in observation for four days, five days, six days, et cetera. They don't necessarily follow the two midnight rule. So but technically you want to at least make sure that you keep the charge for 48 to 72 hours. You know, even though your providers are bringing them back on time, you know. We want to know what the end status of that patient is. Thank you. The next question is, can you bill a visit under your name if you supervised an APP and spent enough time in the outpatient visit. Are there any rules around this? Oh, if you wanna do the work and document the visit, you can bill under your name. I mean, that's as simple as it is. There is an incident to policy, which are strictly for follow-up visits, okay? And that's a Medicare incident too. And what that is, is you see the patient as a new patient, you bill that new patient visit, you establish the care plan for that patient. If the patient comes back in follow-up and sees the NP, if the NP does not change the care plan that you provided originally, we can build that visit under the physician in clinic without you having to re-document or see that patient. That's incident too. But as far as if it's a new patient, nope. It's you or her, or you are the MD or the NP. It has to do the work and bill for it. Yeah, and our next question is, do you have to have a copy of the conversation to bill online digital E&M? No, there has to be some documentation of what was done during a bundle of services, or if it's a telephone visit, what was discussed in your plan. Just has to sort of cover the basics of what you need for continuity of care, medically, legally, and that's really it. And needs to refer to total time of that service because it's time-based. So that's kind of the trick, is just make sure you have that much documentation done. And generally I'll kind of do a little summary note so that it supports my billing, and I'll actually put the code that I'm going to bill, and then send a task to my biller, bill 99421 for this diagnosis or that diagnosis. Our next question, a little bit on the same lines. Do you need to notify the patient that there will be a charge for telephone E&M clinical care? Will the co-pay deductible apply to this visit? Yeah, patients should know what your policy is. It doesn't have to be every single time you do something like this, but they should be aware there will be co-pay and deductibles that apply, and they should be willing. You don't need a signed consent or an ABN or something like that, because they are covered services. So it can be just kind of covered as part of your office policies that when a patient becomes a new patient or gets an update once a year, that it's kind of part of their background information. So they can't claim it's a total surprise. Of course, they don't necessarily read all that documentation, but at least you've told them. Next question is, can a patient have a colonoscopy? And I think they mean screening colonoscopy here. After a negative Cologuard, the patient has never had a colonoscopy. Oh my. Oh. I was gonna ask that question. Well, what is it? Well, I mean, it's probably payer policy, but like Medicare, Cologuard is every three years. So if it's normal, you're stuck for three years. Yeah, there's nothing that specifically says that, and I have yet to see a claim rejection. I may be, I mean, I don't know. Well, the thing is, is that the patient, it says after a negative, we don't know how long. So if the patient had a negative Cologuard two weeks ago and they wanna have a screening colonoscopy yet, well, first of all, they're probably gonna get a denial that they've already exhausted their screening benefit for the year. All right, so that's gonna be based, and I think the question lies verifying with eligibility with the payer. I mean, that's the thing that you're going to have to do. I advise in those circumstances for Medicare, you get the patient to sign an ABN or a similar waiver for a non-Medicare patient. So at least they've been warned this might not be covered because you just did this as a screening test, and we may or may not be able to tell the policy from your payer. I think that's the precautions to take, but it actually seems to work, but I would take those precautions. Yeah, I mean, this is a good out of packet if it does get denied. So it's kind of like, why didn't you just have your screening colonoscopy? That's the gold standard. It's the gold standard, exactly. That's all we can say. Yeah, just do it, go ahead and do it. Well, that was a great discussion, probably on a lot of people's minds. Cigna and UnitedHealthcare have a bulletin as well for history of polyps, and we send that link to patients. Oh, this is just a comment. Yeah, I mean, UnitedHealthcare specifically states in their policy that once you have polyps, all future colonoscopies are not, well, they don't say not preventative, they say diagnostic medical. That's the best thing you can do is give them information from their payer. Yeah. Great. When coding for family history of polyps, we have to code to the last digit, but some payers do not accept Z83719. Is this the same one I read earlier? Yeah, we already answered that. We already answered that. Next question. If a patient has a colonoscopy and a polyp is removed, but the specimen goes to PATH, it comes back not being a polyp with a diagnosis code we can report. Will K6389 be reported? Oh, my take is if I see, if the provider sees a polyp, removes it, sends it to PATH, and PATH shows that it's just some irritation of the colon or whatever, they just thought, you know, yeah, I think that's a good code. It's a funny looking area diagnosis because it supports that, hey, I looked and saw something funny. It didn't come back as anything specific. Okay. And just a reminder, folks, you know, we're scheduled to go to five. So if you have more questions, please, you can either raise your hand, we can open your phone line, or go ahead and type them in. We've only got two questions left. So we can always wrap early as well. So next question is, this is for split sharing in terms of attestation. Can you bill under physician if entire medical decision-making is performed by the MD? Attestation is not extensive, but states that you did entire medical decision-making. So I, okay, this is, I'm an auditor, okay? So I'm gonna look to the definition of a split shared visit. And you have to, if you're billing under the doctor, because you perform the decision-making, you have to perform two of the three components. So in your attestation, I would need to see two of those three components documented. I'm not sure that I would accept just as an addendum that says I did those components. What do you think? No, I would say that, I mean, technically, if you're looking at the advanced providers documentation, and they've got really detailed in order for you to bill under your name. So yeah, that would not be considered. To me, I would not be billing under the doctor. Practice recommendation, document the two of the three and what that was. What did you address and what's your plan? That's my recommendation. So the two of the three, the complexity, the amount of data as well as the risk. All right, so that's what we're talking about. And I think sometimes when you say two of three, people are saying, oh, the history and exam. No, no, no. Oh, no. This is- And that was kind of, that's what I addressed in the split share talk is I went through exactly what CPT stated. It has to be two of the three of complexity of problems, data and risk. And so I would need to see that in the addendum. Okay, so this is the last question we have for now. And I think you just addressed it, but I will ask it anyway. So you can tell me if you did or you didn't. For outpatient, when the physician sees the patient with an APP, how does it work for split sharing? Any rules? That's that lecture you did, is that correct? Yeah, there is no such thing as a shared visit in the office. Now, there's different payer policies out there. And here's the thing. Split share is not every payer. Incident two is not every payer. There's a lot of commercial payers out there right now. If you look at their policies, they say you bill it under the provider that performed the service period. So you have to know who your payers are. And if they accept claims under your APPs, and if they do, if they're doing the work, you bill for the service under their NPI number. Again, unless it's a shared visit in the hospital or it's an incident too, like the actual requirement by that payer is met to bill under the doctor instead of the APP. Because again, guys, payers are looking at this as a money. It's a financial issue too, because you're getting paid a little bit more when the doctor sees the patient than when the NP bills for that service, so. Incident two is risky. When you look at the guidelines for incident two billing, it basically states that if you alter the treatment plan that was initiated by the physician, all right, and pretty well in any shape or form, without an input by the doctor, again, without the physician seeing the patient, then technically that's not incident two. And that should be billed under the advanced provider. So, you know, all of your providers have to be educated on this. And unless you're really looking at every single visit note that's done by your advanced practitioner, I think you'd be surprised that a good percentage of them would not meet incident two requirements, all right? And it's, that 15% differential does not amount to that much money when you're talking about an office visit in particular and a follow-up visit. You know, sometimes, you know, if you've got a high level a little bit more, but on the average, it's around maybe $750 to $10, you know, so is it worth the risk associated with it? So we do have a hand raised and I've gone ahead. You might have to unmute yourself, but Kalpen, please feel free to ask your question. I have a same question in regards to what you are discussing. Sometimes what happens is if I am in office with my APP and this is a follow-up patient, I may go in, talk with the patient, get the history. And once the patient is seen, whatever note my APP has returned, I take over and do an attestation. Does it, you know, count as a visit under me or should be billed under her? Yeah, and I'm gonna say it's payer specific. And, you know, if I'm looking at a note and they did the majority of the documentation, they're most likely going to want that billed under the NP. If they don't do the shared incident to thing, I don't have it. There's no payers that I am aware of that allow shared visits in an office setting. And to me, that describes more of a shared visit. So I would just go ahead and just do the documentation yourself. If you're gonna bill, if you wanna bill for that service, I would go ahead and just document the entire encounter. That's my opinion. Again, unless it's an incident too, then that's different. Incident two is different. Now, this is not an incident too and I'm a hospital employee. What is the risk involved for me? Let's say, you know, my hospital is reimbursing me for those visits. Is it something which, you know, can come back to me in future if my hospital system says, you know, the insurance did not reimburse or whatever? Because as an hospital employee, I do get those RVUs. Okay, so I guess I'm confused because I thought you were saying these patients were in the office. Yes, so let me give you a scenario. This is a hospital owned office? Yes, this is hospital owned office. Let me give you a whole scenario. I have my own APP. There are a few days when we are both in office and we have the same panel because she is my own APP. I see the patient, she does the note, but, you know, most of the time I do the entire MDM because plan is what, you know, we dictate. And then once she writes the note, the note is transferred to me and then I do the attestation part. And the note visit comes under my name, not under her name. That might be a good scenario. I'm not, because is that then billed under hospital owned clinic? And would that be acceptable for a shared visit? I'm not, I don't know. I'm not sure. This is an outpatient setting. First, you have to be both employees of the same system or same entity. Is there some situation where the physician is employed by a medical group that's contracted with the hospital, but the hospital is the employer of the APP? Then that doesn't work. Both are the same employer. Okay, that's number one requirement. I think the minimum would be that you would need to be documenting your assessment where your thought process is obvious. And that's major part of the medical decision-making and the plan for whatever testing or treatment where the risk part is taken into account based on your thought process and is clearly documented. So two of the three key parts of medical decision-making are yours and are documented by you. I think that would be probably adequate and probably would be looked at legitimately for then billing under you. But if you're just doing a more simple attestation, that's not going to cut it because you're creating a new plan for a patient. Okay. Thank you. Thank you for your question. And we have another question that came in and they're asking, does ASGE have common 2024 GICPT and ICD code lists for healthcare providers to use? A list of different modifiers with description. Well, nothing's changed with the modifiers and they're part of the ASGE's primer. We are going to be publishing a 2024 update for CPT, which will have some of the newer information, although there's not much new in the way of CPT codes, but it'll have some of the Medicare rules and some of that. It'll have the new G code, which we didn't really talk about today for an add-on to a visit when you're kind of the person taking care of the chief problem the patient has. You'll be able to bill a G code that will pay a very small amount in addition to the E&M service. We'll be publishing about that. So, you know, some of this is in existing publications and the modifiers are all in the CPT. So you don't have to look beyond CPT for that. But there was a chapter in the primer that discussed about how to use the modifiers. Well, we have no further questions. We can give it a second here. Yeah, go ahead, Dr. Lipper. It was, I think, asked and maybe it was answered online, but I really have the same question. You know, it was stated during a colonoscopy with a bad prep, if you don't get to the cecum, you can use a 53 modifier. If you get to the cecum, but you still decide the patient needs to have a repeat colonoscopy, not a rare scenario. Bowel prep in the right side is often much poorer than further downstream. Can you still bill that as a 53 modifier, bring the patient back? For Medicare, yes. So Medicare still has the old memorandum that was published back in 2003 that states that if the intent was screening and say you can't get to the cecum, or even if you get to the cecum due to a poor prep, you're gonna have to bring the patient back sooner, then the 53 is appropriate. Now, the commercial side follows the CPT guidelines, which say you gotta get to the cecum. And if you get to the cecum, then it doesn't qualify for a 53 modifier. So remember, anytime with the 53, it's gonna be subject to review. So there's three things that have to be documented by the physicians. How far did you get? Why couldn't you complete it? And when are you gonna bring the patient back? So those are three things that have to be documented, and that's what the payers are looking in. They're looking to see if those three requirements are met. So if you're dealing with a commercial payer that says, hey, we follow CPT, you got to the cecum, it doesn't qualify for a 53.

codes 45385

codes 45380

same location

transverse

denials

commercial insurances

Medicare insurances