2025 Gastroenterology Reimbursement and Coding Update (On-demand)| November 2024-12

12 - Top_Denials_in_GI

Pdf Summary

The document, presented by healthcare consultant Kristin Vaughn, focuses on understanding and avoiding common claim denials in gastroenterology (GI) practices. It starts by explaining that despite advancements like electronic health records (EHRs) and claim scrubbers, claims are still often denied at the payer level, costing practices significantly. Vaughn highlights the financial impact: while filing a claim costs an average of $6.50, resubmitting a denial can cost $25 to $118, emphasizing the importance of submitting accurate initial claims.<br /><br />Denials in gastroenterology often arise from bundling issues, and Vaughn stresses the careful use of Modifiers 59 or XS to indicate separate procedures and sites. Documentation must be precise, particularly when different techniques or locations are involved in treatments. The use of correct diagnosis pointers is crucial to prevent denials.<br /><br />Another denial category is "Visit Denied as Global," where Modifier 25 becomes relevant. Vaughn explains that using Modifier 25 allows separate billing for services provided on the same day as a procedure, provided the services are distinct and documented as such.<br /><br />Place of service errors occur when the billed service location does not align with where the patient received care. Healthcare providers are advised to delay billing for observation services to ensure the correct place of service code is used.<br /><br />Vaughn stresses the importance of understanding diagnoses exclusions within ICD-10 codes and avoiding unacceptable primary diagnoses, which can lead to denials. Finally, she advises medical practices to not immediately write off denied claims but to investigate and potentially appeal. This proactive approach can lead to overturning initial denials, utilizing medical necessity evidence, and involving patients in the appeal process when appropriate.

Keywords

claim denials

gastroenterology

electronic health records

modifiers

documentation

diagnosis pointers

modifier 25

place of service errors

ICD-10 codes

appeal process