All right, so webinar overview on this one, I should say, is endoscopic ultrasound, EMRs, semicostal dissections, necrosectomy, EUS, endoscopic gastrocontinous fistula closures, the EDGE procedure, the POEM procedure, the GPOEM, the TIFF, optical endomicroscopy, and then proper documentation and claims processing for advanced procedures. And I know that some of you who are listening are doing these. And I'm going to tell you, sometimes it's very difficult to get an unlisted procedure paid, and I think you're all aware of that. So I'm going to give you some tips on this. But first of all, before we talk about unlisted procedures, we're going to talk about EUS. So in January of 2014, which was the last official update of all the upper endoscopy codes, including ERCPs, the code 43237, which is a limited EUS, was revised to include less than three areas of the GI tract with adjacent areas. And prior to 2014, it was billed when the EUS was only done in the esophagus. It said limited to the esophagus. So some of you have not updated charge tickets to this, because we've been seeing some issues with this. So in order to bill 43259, which is the complete EUS, the physician has to document that he or she examined all three areas of the upper GI tract with the use of ultrasound. So when performing an EUS and a biopsy done separate from the site that you're looking at with EUS, also you have to be specific in documentation as to location. And we're going to be able to bill that biopsy separate, and that's 43239, but make sure that the diagnosis also is specific to the EUS and specific to the biopsy to indicate separate lesions. So it's ranking the diagnoses again. Be prepared to submit documentation, because it seems like this is very common. Even though you attach the 5900, and also there's a possibility of using what's called an excess amount of virus, and either or on that, the payer is sometimes still going to look to make sure that your documentation supports it. So this is just an example. And we're looking at an abnormal pelvic imaging scan, elevated liver enzymes, and right upper quadrant abdominal pain. And I am not going to read through this whole thing, but you can see what's italicized and underlined is the esophagus, stomach, and duodenum were visualized endosynagraphically. That is what you need to have documented to support the complete EUS. And then we see the endosynagraphic findings in there specific as well. And before that, I'm going to go in there. It says endoscopic findings, and it says patchy, mild erythematous mucosa was found in the gastric body. Biopsies were taken with full cold force prehistology. So remember that you're actually looking at the EUS for the more the biliary obstruction. So this endoscopic biopsy of the stomach is separate from the EUS. All right. So then there was dilation in the common bowel duct. There appeared to be a distal CBD structure. There was no sign of significant endosynagraphic abnormality in the liver. No masses were identified. Endosynagraphic parenchymal abnormalities were noted in the entire pancreas. No lymphadenopathy seen. And then we have a path report back for the stomach biopsy that did not show any type of significant abnormalities. So we're able to build a 4.3259, which is the complete EUS with the diagnosis of the right of a quadrant abdominal pain, the abnormal liver studies, as well as an abnormal abdominal ultrasound. And then we have 4.3239 with a 59, or the excess modifier, with the diagnosis of K31.89, which is other abnormality of the stomach. Remember, as long as you found something, all right, even though pathology returned it as normal, we are going to utilize that abnormality diagnosis. All right, EMR. Okay. Big issue with EMRs, all right? And we've been seeing, especially UnitedHealthcare and some of the other payers as well, all right, EMR pretty well means submucosal injection, a snare, or a specific instrument used to remove the tissue. It includes pretty well everything. It includes the biopsy that might be done, it includes any type of ablation of remaining tissue, it includes any type of control bleeding. Do you see what I have highlighted here, the term demarcation? We have seen payers completely deny the EMR, and they come back after the review with the letter because demarcation was not documented within that procedure note, all right? So I'm going to tell you right now, guys, you have got to document that term in there. You also have to document that you did an endoscopic mucosal resection, all right? If you don't document that you did an EMR, and you did not document that the injection was done to demarcate the lesion, then technically we are seeing denials based upon that, you know? Yeah, and it's so frustrating because I pretty well know why you're doing it, but remember, you're dealing with auditors looking at this claim, and they're looking for specific buzzwords in there. If they don't see it, you don't get it, all right? So why this is looked at so closely is because payers consider this a second step or stage service. And it seems the majority of times this gets looked at when we're using a PT or 33 modifier on the claim, all right? So I think, you know, way back when, when this code was actually assigned, a good percentage of our GI docs did not do EMRs, all right? So they did it. They looked at it. It was assessed how probable. They did a biopsy and go, okay, we're going to send this to an advanced GI to do this excision, to do this EMR. And that's not as much the case anymore. A good percentage of our endoscopy providers will do EMRs now, and they're not going to just biopsy and wait for the results and do a second step because it can increase the risk to the patient because now you're dealing with scar tissue, all right? So because a lot of times this is done during the screening procedure, that's often what triggers the review of this claim. And so that's what they're looking for. So make sure that your documentation states that you did an endoscopic mucosal resection. So this is an EMR of a complex rectal polyp. Again, I'm not going to look through the complete and read through this completely. But you can see that this was a 30 millimeter polyp was found in the rectum. It was sessile. The polyp was removed after demarcation with ORISE injection lift technique. Polyp was removed with piecemeal technique. Resection and retrieval were complete. APC was utilized on the edges to close the defect after EMR. Six hemostatic clips were successfully placed. There was no bleeding at the end of the procedure, all right? So we actually have 45390, and when you look above that, there was also a four millimeter polyp found in hepatic flexure that was removed with a snare. So we have two techniques done to two separate lesions, and both are billable. So 45390 is primary because it has the highest value, and 45385 is secondary. And what just blows our mind when we deal with modifiers is we normally don't want to put that 59 modifier that says, yes, it was a separate lesion. I know they're bundled together on the highest value, but on some things we do. It's based on NCCI edits, so if we actually put it on the wrong modifier, we can affect the claim processing, and we can get a denial back on that. All right, endoscopic submucosal injection. So we're looking at similar to the intent of an open excision of a lesion, all right? And there's really not a comparable code for a laparoscopic because there is no laparoscopic approach for this, all right? Well, there is a laparoscopic approach. There's not a reportable CPT code for laparoscopic. So this is also known as a full thickness resection, and it's an advanced technique. So we're looking at, say, 45399 for the colon. You would use RVUs comparable to 44110. If you're using it in the esophagus, you're going to use RVUs comparable to 43100. If it's in the stomach, it's going to be 43610 or 43611. All right, so again, we're looking at an unlisted procedure code for this. So rectosigmoid colon carcinoma in situ found during previous screening colonoscopy. So now we're doing a sigmoidoscopy with a full thickness resection, and it just pretty well says an Invesco FTRD device was placed. It was grabbed with the FTRD. Clip was deployed, et cetera. Resection and retrieval were complete, and a clip was also applied. There was no bleeding at the end of the procedure. So what we're going to do with this one here is we're going to utilize 45399 with a fee similar to 44110, which is an endoscopic excision of the lesion of the colon. And then, of course, you're going to be carcinoma in situ of the rectosigmoid. All right, endoscopic pancreatic necrosectomy. Oh, goodness. This is probably one of the more complex procedures, and this is actually common. It's going to be an unlisted procedure code. And you're going to use code 48999, which is an unlisted procedure of the pancreas. Now, the RBUs comparable are going to be 248105, which is an open pancreatic debridement. And when you guys look at that, the RBUs for this is 85. It's huge. All right. But this is a high-risk procedure, and it definitely is very tedious. All right. So if you're reading through this, this pretty well describes the procedure. And again, I'm not going to read through this. But I want you to actually look at the endoscopic graphic findings that are in here. Remember, you're looking at this. This was a large fluid collection posterior of the ball of the stomach, displacing the stomach. The decision was made to create a cyst gastrostomy using the Axiostensis system. All right. Now, the cyst gastrostomy is separately billable, because you're establishing connection between the stomach and the pancreatic cyst. All right. And then you've got the endoscopic findings as well. And then there were two stents placed through the Axios into the walled-off necrosis. But look at this right here. The cyst was partially filled with black necrotic tissue that was pasty in adherence. Necrosectomy was performed with a snare, requiring numerous intubations, which took over two hours. All right. That is the kind of detail that you want to put in this. Because of the fact that you know anything that's going to be an unlisted procedure, all right, is going to be reviewed. It's going to be reviewed to determine payment. All right. So we've got 43253. Oh, sorry. All right. So now let's going to look at an EUS with fiducial marker placement with or without injection of a therapeutic substance. There actually is a code for this. It's 43253. And it is the most extensive procedure that you can bill. And it can only be billed if both a EUS guided biopsy and injection and replacement of markers are done. And I know a lot of times that there will be two things. There may be an aspiration of a cyst. There may be a biopsy done, an FNA done as well, and along with the fiducial placement, but only one can be billed in the 43253 is considered the most extensive procedure. So this is considered a celiac plexus block. This is an example. So this is a patient who has chronic pancreatitis, and they're doing a block for pain secondary to that. So you can pretty well see the description of the procedure. All right, there was no endoscopic finding. No lymphadenopathy was seen in this. The block was performed. All right. So this is truly just the 43253. All right, so polling question number one. A full EUS with an FNA, 43242, was done to the cystic lesion in the pancreatic head on a celiac plexus block was also done for chronic pancreatitis. Choose the correct codes for billing. So would you bill 43253 and 43242? Would you bill 43242 only? Would you be billing 43253? Or would you be billing 43253 and 43259? Okay. Actually, the only thing you can bill is 43253. That is considered that, remember the block, the celiac plexus block, 43253, is the most extensive procedure. So you cannot bill the 242 with a 253. All right, and that goes back to CCI edits, correct coding initiative edits, right? And no modifier actually will bypass this edit. So all you can bill is 43253. All right. Endoscopic closure of a fistula. All right, and I know you guys do this as well. And it seems like the most common one we see is a closure of a gastrostomy site. So it's actually considered a gastrocutaneous fistula. All right, so when you're using this, 43999 would be an unlisted procedure of the stomach. And your comparable code would be 43870. Could be small intestine, it could be colon, either one. And it's pretty well comparable to 44640. And then for the rectum, it's close to 57300. So again, you kind of have to look at the description of the procedure. But again, this is an unlisted procedure. So here's one that, like I said, one of the most common ones that we see. So a gastrocutaneous fistula was adjacent and below the PEG bumper site. The opening to the skin surface could be seen from the inside. Using the Apollo end of suture advice, the wound suture was used to close the fistula. No air bubbles at the fistula skin surface was seen. And everything was done correctly, okay. So we actually have billing 43999, which is the unlisted procedure. And the PEG would be based upon 43870. And actually the diagnosis code for this is a gastrostomy complication code, K94.29. So, you know, I see this a lot. I deal a lot with the pediatric side. And so they do this very, very common, all right, for this to be done. And so the diagnosis code is K94.29. But, you know, a lot of times when you're looking for a diagnosis code, it actually comes up as gastroduodenal fistula. And that's wrong, that's not the diagnosis code. It's actually a gastrostomy complication. All right, edge procedure. All right, so this is a, and it is a novel technique. So basically we're dealing and performing an ERCP with somebody that has a, usually a Roux-en-Y procedure, all right. A lot of times it's done for weight loss. It could be a sleeve gastrectomy. It could be somebody, like I say, has a Roux limb. So, you know, you're looking to establish a link between the stomach to the small intestine so that you can actually put a scope straight through there. You don't have to go retrograde and up into this. And of course, you know what? There's no code for this. So a lot of times this is a two-phase procedure. First of all, you're establishing the connection. And then that would actually be billed as an unlisted procedure code. Now you could bill it as a 47999 code because you're trying to establish a link to the biliary system. And I know I have listed on the slide, but you could actually do this as a 43999 code because you're connecting to the stomach as well. But regardless, it's an unlisted procedure code. You can use the RBUs comparable to the cyst gastrectomy code of 43240. And so once you have that connection, it seems like that's established first and then the ERCP is done days after that. So once the link is established and now you're doing that ERCP, standard ERCP codes can be reported for this. All right. The POM procedure. All right. The Pororal Endoscopic Manitomy Code. We have a code for this and actually it's been in effect since 22 and that's 43497. All right. So, you know, actually the RBUs are similar to the laparoscopic orthorhizotic approach. And actually this is a 90-day global procedure. We do not have a lot of those. All right. Now there's a GPOM. Now this is actually for gastroparesis and there is no code for this one, but you're gonna use this, you're gonna build this as 43999 and your RBUs are gonna be comparable to a Polaroplasty code of 43800. The TIF code. And I know some of you do this and a lot of times you do it in conjunction with general surgery because oftentimes the patient also has a hiatal hernia repair done. Our hiatal hernia repair, they repair that and then you will do the TIF procedure. If you do this with a general surgeon, this is a co-surgery procedure. And so you would either be reporting this with 43281 or 282, whether or not a patch was done at the time. And you each would build this code because it includes fund duplication. That's the definition of 43281. It says includes fund duplication any method. That would also include 43210. All right. If you do the 43210 only, that's all you do. The patient doesn't have a hiatal hernia repair done, then you build 43210. But if you're building this with a general surgeon, and this is not gonna be an emergent procedure, this is gonna be elective. So that means your staff needs to pre-authorize this procedure as a co-surgeon, right? You have to work together. So the coordination between two offices is essential. Optical endomicroscopy. This means that you're using an endomicroscope that is attached to the esophageal. And so you're gonna use, there's a code for 206 for esophagoscopy versus 252. And then if this is done with ERCP, there is that wonderful T code that you would build along with your ERCP codes. All right. So let's talk about the appropriate billing for unlisted procedures. And again, we know that payers are automatically gonna deny any unlisted procedure code and request documentation. So one of the things that you're gonna do is the documentation should be a cover letter. And you wanna describe the procedure in plain English. All right. And so you wanna make sure that you can use diagrams, you can use highlighting, making notes on the operative report. All right. And then also don't forget to submit the documentation medical necessity to support the decision to perform the procedure. And you can actually do report clinical trials. You can report all of that stuff and send that along with it. Make sure that your documentation states complexity and time. And like I said, with the necrosectomy, I said, you put how much extra time it took. So it says, you know, it's like extremely complex, doesn't create a visual procedure in the claims reviewer's mind. They don't know what that means. All right. So how long did it take you? So patients should create, like I said, providers should create cover letters. It should contain information as to the benefits of endoscopic versus open laparoscopic procedures with shortened in outpatient stays, return to work, and of course, obviously less money from the payer and the patient. So you also want to try to gather as much information from the hospital as to the cost of hospital stay for invasive procedures as a comparison cost analysis. And you can actually find this information on, it's called an HCUP site. And I've got the link for you as well there. You know, bottom line is the payer's looking at money. All right. And if you can save the payer money as well, increase the patient's quality of life as well, you pretty well got, you've got a winning combination. So claims must include a procedure description in box 19. This is probably the biggest issue that we have for billing. If we do not have a description in box 19 of this claim, all right, the Medicare will deny it. So we're your commercial payers as unprocessable, which means you have, it's dead in the water. You have to do an error logging adjustment on the claim and submit a new claim with the description in box 19 in order for them to start the process. You always want to wait for the denial to submit the appropriate cover letter and documentation of the unlisted procedure code. So if you put that description in box 19, all right, it will trigger a request for additional records, which usually means that you'll get an EOB, it's still not paid, but it'll say further information required. All right. You want to create the fee schedule that is appropriate. All right. And I already told you, I gave you some comparison codes for this. Here's just a cover letter content. And this has to deal with a pancreatic necrosectomy. And I'm going to read through this for you because this is really important. This is the kind of information that your provider should be documented. And you can use this as an example. All right. So this was one by one of our practices that we deal with. So X, our patient X has been followed by our practice when first presented with acute pancreatitis and pancreatic pseudocyst. Acute pancreatitis is associated with a significant morbidity and most common causes of inpatient hospitalization. Acute pancreatitis can lead to the formation of a pseudocyst. Patients with walled off pancreatic necrosis are sicker with a higher risk of death for an underlying disease. If the necrosis is infected to the risk of death as high as 20% are one in five, Cleveland Clinic, seven, 10, 20, 20. So they're given examples information. Smaller pseudocysts are left to resolve on their own, but once they become large and symptomatic, they will not resolve and must be drained and debrided to prevent a life-threatening infection. Removal of this dead tissue is imperative to avoid the formation of a life-threatening infection from the debris. But to remove the necrotic tissue, a forceps is inserted through a stent in the stomach that passes into the pancreas, bringing the dead tissue from the pancreas into the stomach, mechanical debridement, piece by piece in a segmental faction. This procedure is very time-consuming, averaging well over one hour for debridement once the connection between the stomach and the pancreas is established. The unlisted procedure for 8999 was endoscopic pancreatic necrosectomy. It is extremely specialized procedure, which takes the same amount of time and training as an open debridement. Endoscopic pancreatic necrosectomy is classified as a notes procedure. And this is if less invasive than the open and combines both endoscopic and surgical techniques, and thus should be reimbursed the same. If you have any further questions, please do not hesitate to contact me at blank. Thank you. So this is a really good example of what your cover letter should contain. And you can take this also from the other unlisted procedures that you might also be submitting. All right, thank you very much. And I'm gonna turn this over now to Kristen. She's gonna talk about ICD-10 and medical necessity.

advanced endoscopic procedures

coding and documentation requirements

unlisted procedure codes

accurate and detailed documentation

medical necessity

ICD-10 coding