I can't believe it, but we're finally here. Where we're going to wrap up with our last Q&A session, I invite my fellow course directors to show their video and unmute. And we're going to jump right into it. So we did receive a question about Fiberscan, specifically with regards to what to document, how to bill for it. Dr. Lindenberg, do you mind enlightening us with your experience? Okay, say that again. I'm sorry. So there was a question about Fiberscan. Okay. Yeah, the question is about using the ultrasound elastography code for the transient elastography, which is the Fiberscan type of technology. We had a lot of discussion about this amongst the three societies, and we even got the radiologists together with us for a session at one of the meetings to discuss it. And bottom line is we could not come to any consensus that said that you can't use the ultrasound elastography code. And the reason is because the Fiberscan device does show an image of a sort. It's not a traditional ultrasound anatomic image of the whole liver, but even the devices that are showing slices of the liver with some ultrasound-like images, they're really not the same as a diagnostic ultrasound in the extent of the details and the images and what's recorded. And the radiologists were unwilling to say, no, they're different enough. You need to use the 9-1-2-0-0 code without exception if you're doing a Fibroscan test. So they basically left it to us. And we know of many practices across the country for several years have been using the ultrasound elastography code. Nobody's been questioning it. They've been getting paid. We shifted our own method of billing to this about, I don't know, nine months or a year ago. So that's all we can say about the state of the art. There's vagary in the CPT descriptors, and so it's just not been clarified. So I think you just do what you see fit, but, you know, just be aware that it's not entirely settled by anyone's guideline. That would be ruled to be, you know, an ironclad rule. Dr. Littenberg, let's stay with you for a second. We had a few questions from your talk. One, do you employ a pharmacist, or do you know of any gastroenterology practices that employ a pharmacist, and is there any billing with regards to incident two with regards to pharmacy? I know of only one large group, and this is as of a few years ago. They have a fairly large centralized office in Florida. They did employ a pharmacist to oversee their in-house dispensing program. The pharmacist, I think, was just on a salary, and his costs were covered by what they earned from the medications dispensed. It's not necessary to employ a pharmacist in most states where I'm aware of at least a little bit of the dispensing rules available, but, you know, it's not a simple program, and there are various companies that work with practices to set up in-house dispensing. A lot of it is contracts with certain payers for certain high-cost drugs where you need to at least make sure there's enough margin. So it's a complicated thing to get into that. So the states, you know, you may need to look into your state requirements when it comes to pharmaceuticals, but I think in most states you don't need to employ a pharmacist. Great. Thank you. Another question that came up for you was, when it comes to digital codes, will office visit or a series of notes stating what time was spent working on the PARA problem or caring for the patient, what kind of documentation is necessary to support the use of digital E&M codes? I basically, besides just the content of what was discussed, advised, what was done, you know, sent Rx for this or sent lab order for that. I just put a single number like 12M, 12 minutes. I mean, that's, you just have to document time. You don't have to say how much time you spent on any particular thing. There could have been two, three portal exchanges. I don't time each one. It's a cumulative set of times. So when I think I've gotten enough to send my bill or a task, I'll just, you know, put something as part of that little chart note. Great. Thank you. Next question for Kristen and Kathleen. So denial code 237. This person has been seeing a denial code 237 with a penalty. And then for other claims, what is the denial code and penalty? Is it 9 cents, 12 cents? Is it related to MIPS? Totally not an area that I know anything about, so. About the cents part. Or even just in general, denial code 237. Denial code 237 is vague. Yeah, it is. It can mean, I looked at, I looked at, tried to look it up earlier. I saw that question come in and it's, it's a very, very vague. I think you would have to reach out and see what, what exactly they're missing and what they want. The fact that that question involved a penalty, what was a 9 cent or a 12 cent penalty on that. I mean, it can, 237 can involve quality measures, but that's not all it involves. It looks at remark codes. It looks at compliance issues. It looks at potential errors on the claim. So there, there's a whole bunch of things that 237 can mean. And I have a feeling that there's another denial reason on there as well. Great. Thank you. All right. I'd like to open it up to the audience. If you'd like to speak, please raise your hand and then Michelle will be able to grant you access to the mic. We can start off with Dr. Nidhidhika Moma. If you have a question, Michelle can unmute your mic and please feel free to ask it. It looks like he lowered his hand. So, oh, here he comes again. Okay. You should be able to speak. All right. Sorry. I'm still on the TCM thing. I was just wondering, and I put the question just now in the chat box for Dr. Lindenberg. I was just wondering what kind of personnel do you use for that phone call? Is it an RN, an LPN, an MA? Just kind of wondering. For billing for a telephone or the portal related digital service, it needs to be a physician or a qualified healthcare professional. So that's generally you're talking about your APPs rather than just office staff. You know, your MA time is not what's covered in that sort of a thing, or even an RN nurse ordinarily wouldn't be. I mean, you can be kind of sharing that in a way and winds up a physician service, but it really is intended for physicians and APPs. I think, Kathy, Kristen, you agree with that? I was asking about the transitional care, the two-day phone call before the visit. Transitional care. Any staff can make that initial contact with the patient. It's the follow-up visit that needs to be with the professional, but the staff is who's tasked to kind of reach the patient, make sure the visit's set up, try to do like some medication reconciliation, or at least make sure prescriptions got to the pharmacy, patients got their meds, that kind of thing. So that's what needs to be done within a couple of business days, but any staff person can do that. And it doesn't necessarily, it's good to document it somewhere, but it doesn't have to be. Theoretically, there's nothing that says there has to be separate documentation, but it's best that somebody jot that down somewhere. I think, Dr. Lindenberg, it really depends on the risk threshold of your organization. We've been having this discussion on the Q&A, but I'll tell you from my own experience, Dr. MoMA, at my former institution, they were very risk averse. So what that meant was it needed to be a clinical staff because they were following the very letter of what was written in terms of who could make that direct contact, that initial direct contact. It couldn't just be someone that scheduled the seven-day or 14-day follow-up appointment. In that conversation, they actually had to ask about the medications, do a med reconciliation, and then that actually needed to generate a note that was documented in the patient's chart. Now, I see this similar to annual wellness visits. Some practices use an MA to do the entire annual wellness visit, and then the physician just refused. Other practices insist that an RN who has that clinical license be the one to perform the entire annual wellness visit because of the need for an assessment and how the assessment part, a piece of it, that clinical assessment, is not in the scope of practice for an MA. It really depends on your practice and where you practice in your institution. So that would be my answer. That's fair to say, but if, you know, if you have MAs and you don't have lawyers in your practice... All right, I hope that helps, Dr. MoMA. We have a question in the chat about the use of gastric varices, Coil-Aid, and glue. I'm guessing this is really about what code should you use. There was a code earlier for quails, too, and I responded about, well, was it bleeding or was it not? And I think that's kind of the answer to this one, too. So if it was actively bleeding, and controlled bleeding is any method, it doesn't matter. So that's a good code that you would use. Now, if it wasn't bleeding, because this is not a true ablation type procedure, then you would end up having to use an unlisted procedure code for this. And I honestly have not seen this done a lot. So what is involved in this? Can you guys give us a little bit more of a background? The endoscope discovers that there are large gastric varices that are either thought to be at high risk of bleeding, because patients have had bleeding episodes, you happen to catch them when they're not bleeding, or they're stigmata of some recent bleeding, but not active bleeding. And often using, sometimes using ultrasound, sometimes they're obvious enough you don't need ultrasound. You basically are injecting acrylate glue into the varices, or putting coils in. I think the coils are probably done more often with ultrasound guidance. And it does ultimately ablate the varices, but it's not really a direct ablation like you'd think of for other things. So I'd agree with you that it's at this point an unlisted code in that situation. But you know, if you use the ablation code, that probably isn't an outlaw thing to do, but it probably doesn't capture the complexity of it either. Okay. Great. The last question, and maybe both clinical and billing in nature. The audience member asks, if we do a screening colonoscopy, patient was found to have a polyp, and then five years later, a surveillance exam shows no polyps, then five years later, should we schedule a colonoscopy, a screening or surveillance? You know, I would first state, you have to be very specific about what kind of polyp this is. So if it's a tubular adenoma, and you're doing the screening, the surveillance exam five years later, you should put in that Z, the Z code for personal history of polyps, where I think it's Z86, right, 0.10. When you do the next colonoscopy, I know that's changed over the years. And if you find no polyps on that second colonoscopy, then my recommendation would be to consider doing one in 10 years, given that, you know, that you didn't find any polyps on that second colonoscopy. Glenn, what are your thoughts with regards to that second colonoscopy after a negative colonoscopy in a person with a history of polyps? Yeah, it really depends on, you know, what came before, what were the nature of numbers, sizes, details of the polyps that preceded. But if they were kind of garden variety, small adenomas, and follow-up at five years or seven years is negative, I think most people now would say to go to 10 years. But it still isn't screening in that perspective. It's still surveillance because there was a prior polyp history. And, you know, most payers will just continue to follow their policies for screening versus surveillance colonoscopy as far as how it gets paid for. That may seem unfair, you know, if you've had two negative colons 10 years apart and, you know, nothing. But that's... And I think importantly, you would indicate using the ICD-10 code C86.010 that they've had a personal history of polyps. Yeah. Okay. Great. Dr. Sun, you have another raised hand. I didn't know if you saw that. Oh, yes. I'm a... I so apologize if I butcher this, but Dr. Shuguri? Yes, Shuguri. Yes, you did it right. Thank you. So my question, I have an MP that I hired in the recent past, and she goes with me in the room. A part of it just kind of trained her, basically. And at the same time, I'm using her as a scribe when I am in the room. And we have at the station in the end of my note that she is functioning as a scribe. But at the same time, I have her also put orders and prescription medications and orders, which she signs. So is it... I'm just wondering, should I still sign the orders? Or is it still okay that she signs the orders? Because I'm signing the note at the end. I mean, the billing, obviously, is under my name for that office visit, since I am seeing the patient. I don't know if I'm clear. I think what you're doing is fine. I mean, assuming in your state, she has the ability to write those kinds of orders, that's fine. She can be signing them. You don't have to co-sign them. The same with prescribing, assuming she has professional status to do that. So that will not cause a way that she's doing most of the work in a way that may make me that I'm not doing much of work. And the billing is under my name. Well, as long as, let's say, there's a change in care plan, that's kind of what it comes down to for the incident, two things. You do have to be involved in that. So if she's doing a follow-up on her own, and there's a change in the care plan, then she has to bill under her own number. But together, it's not an issue. I presume at some point, she'll be independently functioning. Yeah. All right. Thank you very much. Two more questions about transitional care management codes. The first one is, can more than one provider, two different specialists, do transition of care billing with different practices? The answer is first come, first serve. First come, first serve. Whoever the early bird gets the worm. Yeah. Yeah. Yeah. It's unfortunate, and we've protested that to CMS when these codes were evolving, but that's the status of it. I should have had that in my discussion, but yeah, first come, first serve for that. The great point. And just to clarify again, for that two-day, within 48 hours of the discharge, that interactive contact, can it just be scheduling the office visit for the TCM, or is there more that's involved in that direct contact? Supposed to be medicine reconciliation as part of that service, which some patients, they can't really handle that over the phone. They got to bring in their bottles and so forth. You just do the best you can and document what you've accomplished. And I think that suffices. I think key things clinically are just being sure a patient did get whatever prescriptions they were supposed to get. Did they get picked up? Is there prior authorization? Any hurdles? So that transition for that high-risk patient occurs smoothly, but the medicine reconciliation is supposed to be done. Thank you very much. We're down to our very last audience question. I'm not sure I truly understand what's being asked, so I would ask if the person who's asking this question about the scopes in a way or a list or a website to know if it's flexible or rigid could unmute and ask the specific question. I kind of think I know where this one's coming from. Upper has two choices for the rigid scopes, for the esophagoscopes in particular, and there are some codes beginning at 43191. And I think you're all under the assumption that you do flexible scopes, but I also deal with general surgeons that do rigid scopes. All right, so sometimes they'll go in and remove a foreign body with a rigid scope. So I think maybe from an auditor's point of view that I don't know if we really need to be that specific. It doesn't hurt to put that you did the flexible scope of some sort. On the lower GI side, we've got the rigid practice scopes, practice sigmoidoscopes, but most of the time we start with our codes with the flexible sigmoidoscope and then upwards. And that may be what the coding has to deal with. Okay, great. Thanks, Kathy. Opening it up, when to use modifier 93. Is that a tele? An audio only? Modifier 93 is in your CPT book now, and it indicates that the service that you provided was provided via audio only. This is only in reference to CPT codes in the appendix. I think it's T. Yeah, appendix T. So if you open up your CPT book in the very front, and it gives you all the pages of the appendix, go to appendix T. Those are the only ones that are approved for modifier 93. I was kind of looking through the list. The list is very small, but like your medical nutritional therapy codes are in there. Those are approved for modifier 93, but you won't find like your E&M services, any of that. Thank you very much, Kristen. All right. Any other audience questions? Any comments from the group? Any suggestions? We'd love to hear in real time. We're constantly looking to improve the course. I did, there was a brief hand that was raised and then shot down. Not by us. Here we go. Nope. Oh, it works. Kristen, your hands up now. Oh, I have a question. Dr. Moma, did you have another question or comment? Yeah, I was kind of trying to decide whether I should ask it or not. So, if you have radiation-induced proctitis that comes to you bleeding, so the initial endoscopy, you're doing it for bleeding. And so, I guess you bill for control of bleeding, but for the subsequent ones that you're doing to ablate the lesion, for those subsequent ones, should you now bill, you know, APC for tissue destruction rather than control of bleeding? I love it. You answered your own question. Yeah. You got it. You graduated from the course. Now, it might be a flex sig rather than a full colonoscopy. So, you may have to pick a different code from different family, but yes, that's the right, definitely the right concept. Okay. Wow. We are done, folks. We promised that it'll take a little bit, but we will provide a document summarizing the key themes in our Q&A sessions. I'm going to turn it over to my co-course directors for any final thoughts, concluding thoughts, and then I'll wrap it up, and then I'll give it to Michelle for final instructions. So, let's start with Kristen Vaughn. Thank you, everyone, for attending today, and thank you for everybody that presented. Michelle, everybody at ASGE for working so hard to get the course together for us. They make it very easy on us. They really do. We just show up and talk. Just like Dr. Sun said, if you've got any specific topics for next year, any sort of different style, format, et cetera, please, please, please let us know. We are here to provide, you know, you guys great information, and again, if there's something that you need us to touch on more, just please let us know. Dr. Littenberg? I'd say be on the lookout from the three societies for a coding update sometime in the next few months as we summarize some of what's new and different, and I think particularly as I indicated, we kind of got to wrap our heads around this transition away from some of the traditional telephone service codes and get an idea of how private payers are reacting to the 99441 series getting deleted from CPT, and yet, you know, their codes at CMS doesn't recognize it's messy. So, we're going to give the best guidance we can once we figure out some of this stuff. Kathleen Mueller. Thanks. Can I just say ditto? No. Again, yes, thank you to ASGE, Michelle, Christine, William, everybody that has worked so hard to make this meeting a success, and also, I love the fact that we have the ability to bounce things off of our physicians. Dr. Sun, Dr. Littenberg, you're vital, and that's kind of sometimes we miss that when we do presentations or meetings with some just coding, per se, where it's always so nice to have the clinical point of view to help back up our position as well. So, thank you again, and it's been a joy. Well, the partnership is so truly appreciated, and we so truly appreciate your expertise, Kathleen and Kristin. So, on behalf of my fellow course directors, Kristin Vaughn, Kathleen Mueller, Dr. Glenn Littenberg, we'd like to take a moment to actually thank ASGE leadership for their continued support for this course. I did see Dr. John Vargo and Dr. Steve Edmundowitz in the audience earlier. Thank you again. A great thanks to ASGE staff, Christine Pondelicek, William Loznicka, Elisa Langston, Eric Balkosian, and of course, Michelle Akers, for all your hard work ensuring a successful course. Finally, thank you to our audience, to all of you who participated in real time, and to all of you watching the recordings. We hope you'll use the knowledge, skills, and strategies discussed to enhance your practice's financial performance, and ultimately, to better serve your patients. If you have any further questions, please send them to codingquestions at ASGE.org. That's codingquestions at ASGE.org. Thank you again to Kathy and Kristin for manning that website and those questions. It'll provide more fodder for next year's course in the Q&A, and there will always be changes and updates to coding documentation and reimbursement rules. We at ASGE will be here to help you and to help set your practices up for success. Thank you very much, and I'll turn it over to Michelle. Thank you, Dr. Sun, and congratulations to all of you on a wonderful course. The kudos are coming in, and our thanks to our participants as well. As a reminder, each of you will have ongoing access to the recordings from the course via GILeap, ASGE's online learning management system, when they are available. The course evaluation is now available in GILeap, and once you complete it, you can download your certificate. If you need assistance logging into GILeap, please email practicemanagement at ASGE.org or info at ASGE.org. This concludes the ASGE 2025 Reimbursement and Coding Update. We hope this information is useful to you in your practice. Have a great rest of the weekend.

Fibroscan billing

gastroenterology

digital E&M codes

transitional care management

modifier 93

ASGE GILeap