And now on to information on documentation recommendations for diagnostic studies, infusion services, pathology, anesthesia, and nutrition services. So the first thing I'm going to talk about is diagnostic studies and just the requirements that you need on your reports. Your basic demographic information, you do need to have the location of the facility. Should be hospital, should be your practice, etc. The name should be at the top. Patient name, date of birth, obviously medical record number, the referring provider, the ordering provider, the date the test was started, device placed, swallowed, the date of download, if separate from the date of insertion. Right now that is not a requirement on there, but it will be for the date that the, like for pathology services, we need to have the date the specimen was actually received. All right, so name of the facility, the indication for the procedure, that is so important. You have got to have the indication, it's medical necessity. Description of findings, the impression and recommendations, the date of interpretation and the signature of the interpretation. All that needs to be documented. So one of the questions that we get asked a lot is what date of service do we use when, you know, for our services? Look at the codes we're dealing with. 51,000 codes, we don't deal a lot with those. Those are more urology codes, but we're looking at the 70,000 series, that's radiology services. The 80,000, that's path. The 91,000 is our diagnostic studies as well. So what date of service do we use? The last update that we've had is based on CMS on February 1st of 2019. So what they state is if you're billing this as a global, the date can be either the date of emplacement, swallow service, or the date of interpretation. It's either or, you're fine in doing either. For billing as interpretation only, modifier 26, that means that you don't own the equipment, you're not doing the slide prep, you don't have the lab. The date of the service is the date of interpretation. And for billing as a technical only with the modifier TC, the date on the claim is the date of service, swallow placement, et cetera. So by commercial payers, what do we use? Well, it can be either the date of service or the date of interpretation. Here's where we got another spreadsheet. What do we use for each payer? And sometimes this is tricky. It takes a little bit of research to find out. So salvage humanometry, we're looking at pH Bravo studies, impedance studies, capsule studies, livery elastography, either with imaging or without imaging. Sometimes we get the vendor name. We get questions on that all the time, but we really have to break it down as to what that equipment can do. Can it actually provide an image or it cannot? And that's the differentiation between 91200 versus 76981. Then we've got motility studies and we have anal rectal manometry. And last but not least, EMG. I'm not doing a lot of information on all of these, but these are just some of the studies that we are dealing with in GI. 91035, this is the Bravo, which we know it has an attached telemetry electrode. And since October 1st of 2009, I was going to say 2019, but it's 2009, correct coding initiative policy, which is easily found online, NCCI policy. You'll find this in Chapter 11. The EGD is not separately payable with placement of the Bravo unless done for diagnostic purposes, not just for guidance. So if your physician has, I am placing the Bravo for EGD, well, that's so nice of you to do it. You cannot get paid for that EGD separately. So if, if you're doing it because of heartburn, epigastric pain, if you're doing it for a reason and not just to place the Bravo, make sure these reasons are clear. 91110, which is wireless capsule, right? And it describes imaging for the esophagus through the ileum. And as of 2015, CCI policy was updated also that endoscopic placement of the capsule is not separately payable unless done for diagnostic or therapeutic purposes. All right, not just to place the capsule. The problem with this is because you already have to have an upper GI and colonoscopy done that were negative in order for the capsule to be considered medically necessary. So why are you going to have to do another EGD? You just did one, right? So there has to be a reason. So the patient has dysphagia, they have a gastric outlet obstruction, they have gastroparesis, and that's why you have to endoscopically place that capsule, right? If you are only doing the interpretation, which means that you don't own the capsule, then modifier 26 should be added. And it's usually any other site other than the office setting and place of service could be hospital, it could be endoscopy center, it could be outpatient hospital. If the ileum is not visualized, then modifier 52 should be added to that. It's only covered, like I said, if the previous upper endoscopy and colonoscopy were necessary. You really need to check your payer's information on this for what they consider medically necessary. Some of you are given the appropriate ICD-10 codes that are only allowed for that payer. Some of them don't give you a list of ICD-10 codes, but they give you indications and they also give you exclusions when it's not considered medically necessary. All that information is available on your payer websites. All of the information should be shared with the providers, as well as anybody that does pre-op, as well as anybody that does coding and billing. So should these come back as denied, you need to have documentation, first of all, to support it, and if it comes back as less medical necessity, they're pretty well telling you the diagnosis code you submitted on the claim is not one of the approved diagnosis codes by the payer. Capsule endoscopy of the colon, that was relatively new code in the past few years. All right, so I've got a question for you. When billing for capsule endoscopy and the place of service is outpatient hospital, what modifier is required when your provider is doing the interpretation? Is it 26 for the interpretation? Is it TC for the technical component? Is it C, no modifiers required? Or is it D, both the 26 and the TC modifier? All right, modifier 26 is the correct answer. All right, you are doing outpatient hospital. If you slipped it in your pocket to take it to the outpatient facility, so nice of you to do it, but you can't get paid for it. All right, all you can get paid for is the interpretation only. Let's talk about infusions, and I know we had a question on infusions, so I'm going to talk about that at this point. So documentation requirements for infusions, again, the same demographic information. But guys, the diagnosis or chief complaint is key. Be specific as to why you are doing the infusion. Not just Crohn's, not just ulcerative colitis, not just anemia. Some of you that are infusing iron, has to be iron deficiency anemia. For those of you doing an infusion of biologics, it better be the location of the disease, not Crohn's unspecified yet, UC unspecified. A good percentage of our denial reasons for infusions are lax specificity. So if you're taking care of the patient, and this is your patient, and you've scoped them, you should know where the disease lies. Ordering physician, that is the physician in your practice. And that is actually what's listed in box 17 on the 1500 form under the referring physician. Please make sure that this is a provider in your group, and it can be your nurse practitioner that orders it, or your PA that orders it. That's fine. But that's what needs to be on the claim form. The supervising physician is the billing provider in the office suite. The office suite is placed at service 11, not sitting next door in the ASC doing a procedure and available by phone. It has to be in the office suite. And the question is what, there was a question that was asked, what about my advanced provider that might be in the office suite? Can I bill the infusions under them? And the answer is yes. And are they subject to the 15%? Yes, they are for the infusion service. And the question is, what are they also subject to medications? They can be. All right. Unfortunately, it should not be. Medicare will not reduce by 15%. And I think you all know that when a service is billed under a nurse practitioner or PA, it's subject to the 15% differential. And same for the infusion service. But for medications, you should be reimbursed at 100%. We do know that there are some Medicaid contractors that also reduce the medications by 15%. So best practice is to find out what reimbursement for the NPs, PAs, will they be subject to a 15% differential. And if you know this payer will reduce it, then you make sure to schedule that patient when there is a physician in the office suite. Right. The physician order in the medical record, oh my gosh, that is another one the payers are looking at. You really have twice the amount of records that you have to submit. So oftentimes you have to submit documentation for the order and the patient's visit note at the time of pre-authorization. And then some of the payers want to actually see the infusion record. So that's twice. Why do they need to see both? Because that's what they want. And oftentimes the pre-authorization is done by an outside source for the payer. Payment of claims is done on-site or I should say on-site within the payer setting. And they actually want to see both. And when they look at the infusion record, they are looking to make sure that all of this is documented. Yeah. NDC is submitted on the 1500 form. Serial number has to be in the infusion record. The current order, including the drugs, dosage, and frequency, the strength of medications, the dosage, the total units given, total units discarded, that JWJZ modifier, I'll talk about that a little bit later. The site of injection, IV placement, the route, the start time, and a stop time. You have to have a start and a stop time. Infusioning over 15 minutes is considered an infusion. If you have no stop time, no infusion can be billed. And there are even some payers that if you just decide to do an IV push because it was less than 15 minutes, they still want to stop time on an IV push as well. So we have to have the name and signature of the clinical staff provider, which is the RN, the name and signature of the supervising provider. And if there is more than one separate infusion given, there has to be a start and stop time for each infusion. And sometimes you might, especially if you're doing hydration services for somebody that is dehydrated, separate from the, say, the biologic. We still have to have a start and stop for that. And we know that there has to be vital signs and patient response also documented. And some guidelines and tips for infusions. Just because your provider went into the room doesn't mean you can bill that visit unless there was a chief complaint or issue that occurred unrelated from that infusion. A nurse visit not billed just because the patient came in for the infusion. That is considered part of your infusion service. Medicare does not pay for infusions for any site of service other than office. And commercial payers may pay with site of service 24, but that's subject to contract negotiation. We know that a physician or provider must be on site during the infusion. This is considered an incident to service. You saw the patient first. You determine that the infusion or medications were necessary. And now this is incident to that initial, and it requires a physician or provider must be on site. Prior to administering any medications that are extremely costly and most of what you give is, check with each insurance carrier at the time of pre-cert as to their approved amount that you will be paid. If it's less than your cost, negotiate. And some of the payers, and we're seeing a lot of payers that will actually send you the medication with a fax prescription that's considered white bagging or brown bagging. So the JW modifier, this modifier actually came out in 2017. And that means that this is your discarded drug or biologic. And all providers and suppliers must document the amount of discarded drugs. And you're going to be, this is going to be a two-line item claim. One is the medication that you gave with the appropriate amount of units. And the next line is the medications that you discarded with the JW modifier. The JZ modifier came out July 1st of 2023, and you are required to report the JZ modifier when there are no drugs, discarded drugs, and biologicals. All right, so here's an example. Remicade 400 for Crohn's of the large and small intestine with Worol Benadryl given on arrival. The administration time is three hours. So we've got 413 with a diagnosis of K50.80 and 96415 for two units with the same Crohn's of the small and large intestine. We're going to give J1745 with the JZ modifier, 40 units of Remicade were given. There were nothing was discarded. And oral medications are not separately billable. All right, so the example two, we're giving IV Benadryl and 950 milligrams of Remicade. So we're going to use 96413 and 415. All right, since the infusion time was two hours and 20 minutes, we're only going to be able to bill that second hour. 96375 is the IV Push Benadryl. We're going to bill for the Benadryl, the J code. We're going to bill for the J1745 for 95 units. And we're going to bill J1745JW because five units was discarded. And here are some of the biologic agents for IBD with their dosage. All right, and there are more than this, but these are some of the most common ones that we see. Here are the iron infusion agents. All right, two are false. The billing provider for infusions is the provider who is in the office suite during the entire infusion. Is that true or false? Yes, the answer is true, in the office suite. Pathology services. Pretty well the same thing as far as what the documentation requirements are, name and location of the facility. And we do see some differences on PADS, so if the pathologist is billing with interpretation, there should be the report with his or her practice name at the top of the report. If the lab is billing separately with the TC modifier, there should be a report with the name of the lab who processes the specimens at the top of the report. And then if the service is billed as a global without the 26 or TC, then the name of the practice should be on the top of the report. So there are some differences between that. And of course, the demographic information. We need the date the specimen was obtained, and that's the date that pathology claim is billed under unless there are other specific instructions from that payer. The state the specimen was received and the date the state was processed. The ordering physician is usually the endoscopy provider. The referring physician can also be the endoscopy provider. Okay, this is so important. There has to be clinical history on that path report, right? What if the specimens are normal? Why was the procedure done? It should be specific. It can be based on symptoms, personal history, family history, any type of surveillance of disease, chronic medical diseases. If there is no clear indication, the endoscopy report should be requested to see why. And then that information should be also on the pathology report. A lot of times what we have is an endorider at the ASC, all right, and it drops pretty well kind of a requisition based upon what the indications are, what the findings were. And that's great because then the pathologist will get all the information as long as the endoscopy report is clear. But sometimes the pathologist relies upon an actual requisition that is filled out by usually the circulating nurse, whoever is labeling the specimens, et cetera, and they get that information from the physician. I used to be that. We did that in the office. What are you, why'd you do it? What are you ruling out? And that information was sent to the pathologist, right? So again, it can be either or direct from the endorider, which should have all of the information or on the pathology requisition that should have all of the information as well. And if this becomes a frequent issue where you're not getting history, you're not getting that information, then you need to have a talk with the ASC. So the pathology report also requires indications for stains, not just for histology, but what are you looking at? What are you ruling out? And then the stain type. These are the most common ones that we deal with. The standard H&E, which is 88305, and then the stains that are being done, fungal, bacterial stains, metaplasia, immunostains, again, information as to why these needs to be done. Microscopic description has to be done on every path, and this is done by the pathologist. Then we have size and margins. It's not necessarily the pathologist, but it can be. Margins definitely have to be the pathologist. The gross description is what it looks like to the naked eye. Includes the size, color, number of tissue samples, et cetera. There is a final diagnosis section that tells us what this actually is or isn't, and it will include the tumor grade. Sometimes we get a synoptic report, and then the signature of pathologist, as well as the date of interpretation. The date always has to be on there. There's a special focus on stains by most medical carriers. They pretty well state, you're not going to just randomly step and stain everything that comes out. All right? So if your lab, for instance, you don't own the pathologist or employ the pathologist, you are doing the stain prep, I shouldn't say the stain prep, the slide prep, and your pathologist says, I don't care what it is. You stain everything. You do this stain, this stain, and this stain. That's a problem, right? Because what the focus on stain and the LCDs by most of the Medicare carriers are pretty well stating that the pathologist should look at the specimen first to decide what stains need to be done, not just routinely ordering stains, right? And this is the guidelines. I'm not going to read through each one of these. This has been actually out since 2013, and we do get looked at because we have a lab. All right? So they're saying, oh, well, there's some financial incentive here to stain everything. All right? So again, make sure that the medical necessity for stains is well-documented. Make sure that there are, if you have ownership of the lab and not the pathologist, again, make sure that you are following the orders of the pathologist. I mean, how clear am I on this? How many just different bullet points for stains? Because that is the major focus of the payers out there. Kristen and I were involved with, we kind of got contacted because Blue Cross and Blue Shield came in and we're wanting a recoupment of almost around $800,000 for one GI group. And it was all about stains. All right. That was the whole key on this one. And they ended up, well, we really haven't gotten the final result on this, but I have a feeling that the attorney was going to end up settling with this one because there was definitely an issue. When Blue Cross and Blue Shield comes on site and looks at something, there's a problem. All right. So what about colonoscopies when screening is the indication for the procedure? We kind of talked about this earlier. You know, when you're doing a biopsy for microscopic colitis, again, and the only indication is screening, there's a problem. But what happens if we actually did a screening colonoscopy, we did a polypectomy? Screening should be primary, right? The polyps secondary, but we have some payers that won't allow screening in the first position. So again, use box 19, utilize the comment field, enter screening converted to surgical in there because we want the patient to be eligible for the preventive benefit. Don't assign a polyp code, a D12 code, without pathology to confirm it as a neoplasm. All right. So if the pathologist does not come back with an actual neoplasm, we're going to use the polyp codes. All right. So just some tips, 88305, 312, 313 are build-in units for most payers. Immunostains are a little bit different. If you're reporting an immunostain to a single specimen, you build 883042. If you are doing multiple immunostains to the same specimen, then you would build 88342 for the first and 88341 for each additional stain to the same specimen. The same specimen is the key. Make sure your pathologist or lab is credentialed with each payer. Diagnosis codes that are assigned as primary for each procedure is approved as primary and not secondary. Kristen kind of went over that earlier. And then make sure that path report is signed before submitting charges. All right. So that's procedure billing. Again, demographic information. same thing. Patient's diagnosis has to be there. Why? Why are you doing it? The reasons and findings during the procedure. Right, we do a lot of pathology or I should say anesthesia review and oftentimes remember that anesthesia report, the risk assessment as well as the anesthesia record is what stands alone for your billing. Right, we need to know what was found during that procedure. We need to know why the procedure was being done. We need to know what risk factors the patient had to support medical necessity for MAC. All right, comorbidities are very important and I can honestly say we don't see that a lot documented on claims. Right, and it should be. Some of our primary, some of our Medicare carriers require comorbidities as primary diagnosis, especially for EGD. Not for colonoscopies, for EGD. The comorbidities are your first, first diagnosis code. All right, so physical standards as far as your ASA class has to be documented. The type of anesthesia provided, the position of the patient, the start and end time for anesthesia care, and for the anesthesiologist, we're not talking about moderate sedation here. We're talking about the anesthesiologist. It begins when the patient is, I'm sorry, when the anesthesia provider begins to prepare the patient for induction. Right, and that means that placing a monitor, starting the IV, preoperative sedation, any other medications might be given beforehand, that's when it starts. The documentation of discontinuous time, documentation of the anesthesiologist relieving another, and this is not just anesthesiologist, this can be CRNA as well. If somebody else is stepping in to take over, both of you have to be on the document on the claim, and you're both signing that note. All right, the name of the anesthesia provider, if the anesthesiologist is supervising a CRNA, the name of the CRNA and the name of the anesthesiologist must be on the medical record, and again, both must sign, must include a legible form of the name and credentials. We do see a lot of handwritten records that are illegible. They don't have all of the components and documentation requirements, and this is problematic. We even see electronic records, don't have all the requirements, the fields are blank, right. It should all be signed, it should all be complete and legible. All right, so currently the MAC anesthesia value is 20.77 per unit, and the conversion factor for 2020-2025 proposed is $20.33 per unit. All of the MAC codes that we use have base units assigned, so 00731 for EGD has a 5 base unit assigned. For colonoscopy, we're looking at 4. For diagnostic, 3 for screening, and for double procedures, upper and lower, the base unit is 5. All right, and I'm not going to go through everything on a word for word, but you can pretty well see that the time is in increments, and each additional 15 minutes is awarded an additional unit. So some of the issues with MAC. 00811 is used on patients undergoing diagnostic colonoscopies. All right, so we're talking about patients with symptoms, abnormalities, chronic diseases. For CMS, the PT modifier is assigned for 00811, all right, when the screening colonoscopy is converted to surgical in order to waive the patient's deductible 15% Medicare patient responsibility. Most commercial payers do not follow CMS policy and only want this on diagnostic procedures, and remember, they also consider personal history of colon cancer or colon pops as surveillance and diagnostic, not screening. All right, 00812, this is for patients undergoing screening colonoscopy, and it says regardless of findings in the definition. So for Medicare, you're going to use 00812 when the physician submits a G-code, G0105 or G0121. For the commercial payers, you're going to use this on G0105, G0121, or any surgical colonoscopy with a 33 modifier. And 00813, unfortunately, you can't use a 33 or PT modifier on this one. The most you can do to try and get the patient a preventive benefit is to put screening in the first position, but unfortunately because EGD is in there and it's not screening, you may not get the screening coverage. G0500, this is moderate sedation services provided by the same physician or other qualified health care professional requiring the presence of an independent trained observer. And above that, it says performing a gastrointestinal endoscopic service that sedation supports. All right, and this is the initial 15 minutes, and it's important there has to be at least 10 minutes of time documented in order for this to be covered. All right, we have other codes for this, the 99151 to 153 codes. This is not specific to GI, and these codes were bundled into any of the endoscopy codes as of July 1st of 2017. All right, so best practice, this is used at G0500 to all payers. All right, and this does require either the 33 or the PT modifier in order for that Medicare patient or even our commercial payers to allow the patient to have the preventive benefit services. All right, so this is just an example. A 67 year old patient presents for screening colonoscopy. The total sedation time is 16 minutes. We're going to build G0121 and G0500 with the 33 modifier. Patients co-pay and deductible will be waived. And then for the patient that has a screening converted to a surgical, we're going to add a PT modifier to both the endoscopy procedure as well as G0500. And the patient's deductible is waived, but that 15% co-pay still applies. All right, and I just mentioned this since 2017, the CCI edits bundled the 151 and 152 into it. And remember that not all payers recover this. All right, and the only reason Medicare is paying for this and the commercial payers would pay for this if they took the anesthesia work value out of the fee schedule, right? If they didn't do it, they're not going to pay extra for it. Medicaid has never covered this as well. Now I didn't cover this in this, so I'm just kind of testing your knowledge on this. If a patient has a history of an MI 10 months ago, what ASA category would be assigned? Is this ASA 2? Is this ASA 4? Is this ASA 3? Or is this ASA 1? All right, so remember this is an anesthesia assignment. Most of our docs and providers listening in would know this, and some of you also would know it. Let me just check up knowledge. And here are the results. I have a feeling that this is going to be a little bit different. All right, well it's not ASA 1. All right, but since it's 10 months ago, anything greater than three months is actually considered ASA 3. Anything less than three months is considered ASA 4. Okay, is this important that this be documented in the patient's visit? All right, this is actually a sidebar for our medical decision-making. This is a risk area, guys. This would actually be considered, this wouldn't be necessarily considered high risk, but it actually is a risk factor. Now I have a feeling a couple of our physicians would say, yeah, this is high risk. And because of coronary artery disease, you got to say it. But for anesthesia, would this still be a reason for anesthesia monitoring? They're ASA 3. Yeah, it is. All right, so again, documentation is so important. The past history is very important for the patient. It supports medical necessity for our procedures and for our level visit, but it also supports the medical necessity for our MAC. Yeah, I just wanted to jump in with that prior example. You can definitely justify that it would be high risk because if the patient got a stent, for example, and they still need to be continued on aspirin and Plavix, and you're planning on doing the endoscopy on those antiplatelet therapies, you can justify that the patient is at higher risk for bleeding because they're going to need to be on those medications. And if you document that, you can state that that's high risk. That's important. Absolutely, you need to document it. All right, last but not least, a little bit on nutrition services. And I know some of you do have registered dieticians in your practice, and they are allowed to bill these codes because the codes are for them. What about if your physicians or your NPs, PAs also do medical nutrition therapy? You're billing by time. All right, that's part of your visit. Right, so we know for nutrition services, Medicare does not recognize these codes for conditions other than diabetes and renal disease. It's a cash pay situation. And for commercial payers, it's a good idea to do predetermination, pre-authorization. Some will cover more than just diabetes and renal disease. And I think if you're going to send the patient over for dietary counseling to the hospital, they're going to have to pay out of their pocket anyway. So if you provide the dietary services in your office, it's another, it's a nice service that your patients don't have to run somewhere else for. And most of them realize that it's going to have to pay for them regardless.

medical documentation

diagnostic studies

billing compliance

payer guidelines

infusion services

pathology reporting

anesthesia documentation