All right, so now we're on, um, advanced endoscopy. So we're going to talk about EUS, EMR, ESD, necrosectomy, um, fistulas closures, edge procedure, POM, GPOM, the TIFF, endomicroscopy, and then also some proper documentation, uh, for advanced procedures. So let's talk about EUS. The last revision for EUS was in 2014, and there used to be a code, well, there still was a code, but the terminology changed. 43237 used to say just limited EUS to the esophagus as well, and that's not anymore. So in order to bill 43259, which is your complete, I call it the complete EUS, your physician has to document that he or she examined all three areas of the upper GI tract with the use of the ultrasound, not just the scope got into the, uh, duodenum, but all three areas were assessed. The esophagus, the stomach, and the duodenum have to be examined with EUS, right? So this is just an example. The esophagus, stomach, duodenum were visualized endosynagraphically. It was accomplished without difficulty. The patient tolerated the procedure well. That's the terminology that you need to have in there. And obviously there's going to be the endosynagraphic findings listed below, right? Terminology has to be there or it would be considered a limited EUS. Endoscopic mucosal resection. Oh, this is probably one of our problem areas. Okay. Really CPT book doesn't give us a lot of information in here. If any of you subscribe to the CPT assistant, that gives you more information. Again, we have information in the primer as well. It includes a submucosal injection to demarcate the lesion. Then you've got a technique to remove the tissue and the T marcation with adequate bar borders is actually required. And some of you listening are going, are you really kidding me? And we've had challenges on this by a lot of physicians out there. Do I really have to say that? Well, I'm going to tell you right now. There's two payers that say you have to, and that's Anthem and UnitedHealthcare. And if you don't have that documentation in there, they will not pay you for an EMR. All right. So the term EMR also should be used in the endoscopy report. I did an endoscopic mucosal resection and a complete description of that. EUS can be separately billed, even if it's for the same lesion. It's not considered bundled. This may be required by using a snare tip, an APC, or anything like that. That's all considered part of the EMR. And it's often considered a second step or stage service, simply because we're still looking at, it's kind of payers and still kind of look in the old, old version back when this actually code was created. It used to be a service done only by advanced endoscopy providers. And oftentimes these advanced providers were not within your practice. So step one was to do the endoscopy, and oftentimes during screening, this was found. And then we did a biopsy and then we sent them off to the advanced provider to do the EMR. We don't see this as much anymore. We see a lot of our providers that are automatically doing an EMR, even during a screening colonoscopy. So when we put a 33 modifier or a PT modifier on an EMR, what happens is it triggers a review by a payer. They're like, really? We want to see the documentation to prove that it was an EMR, right? So that's the reason why we often have to submit our notes for review, and this documentation better contain that information. All right. So this is just a documentation in here, just an example of an EMR. And here's another one as well. So we're looking polypers removed after demarcation using a hot snare was removed with piecemeal technique also. So two types of techniques were done. Resection retrieval APC was utilized to close the defect after EMR 6 hemostatic clips were successfully placed. There was no bleeding at the end of the procedure. All right. So we would use the 45390 on this, with that. Okay, ESD. There is no code for this. So we're looking at it's considered a full thickness resection, and it involves an advanced technique to remove a lesion. So we are going to build this based upon the anatomic lesion in an unlisted code. So if it was done in the colon, we would use 45399. And it actually is comparable to an excision of a lesion. It's open. There is no code for laparoscopic excision of a lesion. So you would use RVUs comparable to 44110, and as well as 43100 for the esophagus. And if you're dealing with the stomach, it'd be 43610, 43611. The rectum would have its own code, 45999 code. But you would use comparable anatomic codes. So here's an example for this one. And the Avesco device is often used for this. A slow ooze remained at the end of the procedure. Clip was applied. Again, that's all considered part of that procedure. And that's what you would do, and that would be how you would build to determine your fee. And the description. Like I said, you've got the description of the full thickness resection. We talked about the EMR before. There's a description. You just didn't say, I did this. Make sure that you have a full description. A pancreatic necrosectomy. Oh, I'm hoping one of these days we're going to get a code for this. But oftentimes, and I'm not going to read through this, because in order to get into the pancreas, you have to have access into the pancreas, and it could be through the stomach duodenum. But a canal is formed, which connects these two, and a stent is often placed. We often see a cyst gastrostomy code, where that says 43240, and that is just to facilitate access to that area. Once you're in there, and then you start doing the debridements of that pseudocyst and the necrotic tissue, we're going to use a 48999 for an unlisted procedure of the pancreas. And the relative value units are comparable to CPT code of 48105, which is an open debridement of the pancreas. That has 85 RBUs associated with it. Great. That's a lot. But remember, this is not a simple procedure. It has risk associated with it. And your documentation, anytime you do anything with a unlisted procedure, it is really important for you to make sure and document how extensive, complex this procedure was. So I've got this highlighted. I'm not going to read through the procedure for this. It's as necrosectomy was performed with a snare requiring numerous intubations of the cyst, which took over two hours. And then additional stents were placed. So we're going to be able to bill for 43240, because in this example, the cyst gastrostomy was actually done. So that's 43240. But we also then did the necrosectomy. So you're going to be able to bill both of these together. Endoscopic closure of a fistula. All right. So we've got the most common one that we see is actually closure of a gastrostomy, which is a gastrocutaneous fistula. And you're going to use code 43999, which is unlisted procedure. We're going to use 43870 for closure of gastrostomy as the comparison code. All right. For the small intestine, for the colon, for any type of fistulas in there that you might be doing with the rectum, these are just comparison codes that you can use for this. Here's one for the fistula example. And this would be the unlisted procedure for the stomach. Internal peg bumper was seen. You're doing a gastrocutaneous fistula was adjacent. And then the suture advice was done. No air bubbles were seen. And we're going to bill 43999 with a fee of 43870. And by the way, just ICD-10 code for this one would be K94.21, which is another complication of the gastrostomy. Next we have the EDGE procedure, which is an ultrasound-assisted transgastric ERCP. For these are patients that have no longer the gastric outlet through the pylorus. So again, we're kind of doing a creating a conduit between the excluded stomach or between the stomach as well. And this could also be done as a gait procedure, which is kind of similar for those patients having a sleep gastrostomy. But whatever guys, you're not doing, you're creating the channel. So that now an ERCP scope can be put through it right directly into the small intestine. We know this is not an elective procedure. This is going to end up being an unlisted procedure code, right? And it's going to be an RV use comparable to 43240. The POM procedure does have a code, all right, it is 43497 and that's for echolasia, but the G-POM does not for treatment of gastroparesis. So we're going to use a code of 43999, unlisted procedure of the stomach, comparable code of 43800 for pyeloplasty. The TIF procedure, I kind of mentioned this earlier. This does have a code, it's 43210, but unfortunately a lot of times we are co-surgeons on this because if the patient has a hiatal hernia anyway, we want to make sure and take care of that in order for the fundoplication to be successful. Coordination between two offices is essential. And then the GI would report this as a co-surgery with a general surgeon. Optical endomicroscopy, this is an actual endomicroscope that's attached to your esophagoscope, right? And other codes for EGD, for esophagoscopy, and there's also a temporary code for ERCP. I don't see a lot of our providers doing this one, but it's kind of cool. All right. So here's a polling question. Endoscopy reports for an EMR should contain these documentation bullet points. The term EMR, the demarcation of the lesion with defined borders, full description of the procedure with specific instruments used, or D, all of the above. What do you think? Yes, 86% say all of the above, and that is actually correct. All three should be documented in your endoscopy report. Now we're going to be looking at appropriate billing. I will say, I mentioned just before, the majority of these list of procedure codes are going to have an automatic denial by payers. So in order for these to get paid, your endoscopy report is so essential. You need to describe the procedure in plain English. Remember that when these are being reviewed, it's not necessarily reviewed by another GI provider. Definitely not a provider, or sometimes it's not even somebody that has a medical background. So you want to include documentation in plain English, and I still recommend that you do a separate report that explains exactly what you did. Include diagrams, photographs to help the insurer understand the procedure better. Certain practices do recommend highlighting, making notes on the operative report to indicate where the provider describes the enlisted procedure. Your little history box in there is a very good spot that can give you free text to describe exactly why this procedure is essential for this patient. Be sure to document the complexity, time involved, like I said before, and the term extremely complex doesn't create a visual picture in the claims reviewer's mind. So extensive debridement that you had to take the instrument in and out so many times. It was extremely tedious, foul smelling, and a lot of someone, for those of you that have done pancreatic debridements, you basically said this is some of the most foul stuff that you do remove. So you can use that. You're trying to create a visual in somebody's mind that they want to pay you more money. You should create cover letters for all enlisted procedures performed, and this is really for our doctors to do. It should contain information as to the benefits of endoscopic versus open laparoscopic, to include patient shortened out patient stays, return to work. Overall, what you're trying to do, and sometimes this is what triggers the better reimbursement is you're saving the payer money because you're not paying the hospital as much money, the patient doesn't have to stay in as long, and so it's also less out of pocket for the patient. You can also gather information from the hospital as to cost analysis for invasive procedures, and you can also get that information from HCUP's site, and there's a link on the slide for that. This is an example. I'm going to have a letter in just a little bit, but remember what I said about box 19 of the claim form, and so your doctors and providers listening is like, what is box 19? Well, you're not responsible for submitting the claim, but you are responsible for providing your coders the information to submit on the claim. The coder will automatically deny your claim if you do not have a procedure description in the comment field, and it will read as claim is unprocessable. Your claim is dead in the water at this point. You're going to have to do an error in logging adjustment on the claim, and you're going to have to submit a new claim. You always want to wait for the denial to submit an appropriate cover letter, except if your payer has specific instructions for claim submission for unlisted procedures, but the majority do not. You're going to submit it electronically. You're going to put the information in box 19. You're going to get the explanation of benefits come back that says denied further information is required to adjudicate the claim. That is when you send your information. Most of your commercial payers have the same guidance and denial reasons as well, so always usually wait. There's another reason why sending this electronically. You have documentation that shows that you submitted your claim in a timely fashion. All right, I already talked about creating the fee schedule, and you can base this off of RVUs of an established procedure comparable. Sometimes we don't have a comparable endoscopic procedure, so you're going to have to find something in the open or laparoscopic approaches. This is just a cover letter for content for a necrosectomy. This was actually developed by a physician at one of our practices, and it talks about acute pancreatitis and the formation of a pseudocyst and walled off necrosis, and removal of dead tissue is imperative to avoid forming of a life-threatening infection. This is very time-consuming, averaging well over one hour for debridement once the connection between the stomach and the pancreas is established. Very good format, and we've actually had somebody say, well, can we do something like this for our other procedures? Absolutely. You can use this as an example, and this is the type of documentation that your payers want to see when you're using an unlisted procedure code. The best person to do that is your physician's doing these procedures. The unlisted procedure was endoscopic pancreatic necrosectomy. It's an extremely specialized procedure, which takes the same amount of time and training as an open debridement. It's classified as a notes procedure, and for those of you that are going, what the heck is a notes procedure? That's an ICD-10-PCS procedure code. When you look at ICD-10-PCS, which a lot of you don't buy that book, because that is for the hospital side, they often have way better codes to submit versus the physician's side, but that's kind of where you compare it to. That says, if you have any further questions, please do not hesitate to contact me at such and such. So this is a very good example of the type of content that you should have in your cover letter. All right. Thank you, guys, and I think we have to head on to the next presentation with Kristen.

advanced endoscopy

insurance claims

documentation

procedure coding

reimbursement