questions that were received on the ASGE support line. Obviously, we got more than 10. So, trying to go through and trying to pick out the ones that I thought were good. So, first of all, I think number one, our providers have sparked conversation about Fiberscan and as we continue to investigate the continuum of the service, reimbursement, equipment, I'm wondering if you could provide the most up-to-date literature about billing for this. I've seen conversation through APC about billing 9-1-200 versus 7-6-9-8-1 and whether or not we can build a radiology code if not ultrasound guided, but cannot find any policy as it pertains to that. Any help or guidance you can provide with documentation review would be helpful. This is really totally based upon the device used. Remember that Fiberscan is a brand name and elastography equipment now has many manufacturers and whether or not they can also give you a true ultrasound image and that's 7-6-9-8-1 depends upon the equipment your practice has. So, I would stick with 9-1-200 if you're not producing a true ultrasound image and only using the probe to get the shear wave, right? So again, it's based upon the equipment that you have. Number two, we have several providers, three MDs and one NP joining our practice. Payer credentialing is slow and due to this limitation, it is difficult to find enough patients to fill our new provider schedule. We are trying to combat this issue to see if there's any restriction with pairing the new provider with the supervising provider then have both providers sign the note bill under the credential provider. Is this allowed? Hmm, this is one of the OIG top issues and per the OIG, knowingly misusing provider identification which results in improper billing. So, if a new provider is not credentialed and you work around the delay in credentialing by billing services and this is actually on the OIG website by billing services under the ID number of another provider in the practice, this is considered a false claim since providers may not submit claims without their own ID numbers. I know this is problematic because obviously, sometimes you do not know until the last minute when this provider has signed on or information is not given to the person who does this as soon as possible. There are some delays by different payers out there and whether or not you're allowed to do retroactive is completely up to the payer and if so, it's how many days. So, best practice for this and again, this involves a lot of communication is to make sure that your scheduler is aware of who your provider is allowed to see and as their credentialing process is updated, make sure that again, that scheduler is given a list of those payers out there. If not, you got out of network issues and again, don't go ahead and bill under another doctor who's on site that day. That is considered a false claim. Do images need to be saved to report CPT code 74328, interpretation of bile duct images during ERCP? And I actually mentioned that earlier in one of my presentations and yes, a copy of any radiologic image is required since the AMA and CMS updated documentation requirements in 2018. This is actually in your CPT radiology section guidelines and it says that imaging can be required and when imaging is not included in the surgical procedure, the image guiding codes are labeled radiologic supervision and interpretation may be reported but it requires image documentation in the patient record, description of image guidance in the procedure report and it has to be image documentation in the patient's permanent record and a procedure report is separate imaging, right? Now, the separate imaging report does not have to be a separate report. It can just be also contained as a paragraph like I said earlier in your ERCP record. Right, do infusions require a physician to be on site? Are current Canon NP bill for infusions without a physician and is this the same in all states? Well, I mentioned this earlier. This is again worth revisiting because this is a common question that we get. Office infusions are considered incident-free services so that means that when a nurse is administering an infusion, there must be a provider on site and immediately available. If you have a provider in the endoscopy center next door, they are not immediately available so if you have a nurse practitioner PA in the office, you can still report under their names and we talked about this earlier. The administration can be reduced 85% of the fee schedule and we also had said that some of the Medicaid payers and can also be some commercial payers can also reduce medications by 15%. Now, as for state guidelines, this is something you're gonna have to probably need to research because there are different rules based upon the state in which you practice. Also, don't forget about checking with your mail practice carrier too. They do have some input into this and sometimes we do forget about them, right? When you bring new services in and it doesn't matter in your physician side, then the office side as well as the ASC, always run something by your mail practice carrier. Number five, I have a question, is the code G2211 a proper code to use as an add-on code to our office visits, 9921384, 203, 204 and also with modifier 25? Can we do that? If not, which one has higher reimbursement? Well, again, we started this way earlier this morning, part of the first presentation. G22 can only be added to a visit when there is info in the care plan that you will be managing this condition pretty well, longitudinally or for the long haul and not just an acute issue. If you're adding a modifier 25 to that visit with another service, G2211 is not to be billed since you will only get paid for this and not for the service. And the service, again, is usually definitely higher reimbursement than the $16 you would get for G2211. Number six, we had a 64-year-old patient come in for screening colonoscopy after a positive Cologuard test from the PCP. Patient's mother had a history of colon polyps in her 60s and colitis. Is this still a screening? Some of our physicians are saying that it is an average risk screening due to the age of the mother. Can I get some guidance on this since we go round and round with them at least once a week over Cologuard and other stool tests? Yeah, I imagine you do. Cologuard is indicated for use in patients at average risk, no personnel or family history. I would use caution when eliminating family history because one might feel due to the patient's family member's age, this would not count towards family history, but per the U.S. Preventive Task Force guidelines, family history of anonymous polyps or serrated lesions at any age would be considered increased risk. And Ken, we talked about this before. Family history, and we don't often have pathology to say what the type of polyps is the patient had, but I think most of our providers err on the side of caution and consider them to be adenomatous. You know, otherwise, you know, we may be overlooking some things, but this is CMS's policy for screening versus stool DNA. So it says centers for CMS has determined that the evidence is sufficient to cover Cologuard as a colorectal cancer screening test for asymptomatic average risk beneficiaries, age 50 to 85, and they will cover Cologuard tests once every three years for beneficiaries who meet all of the following criteria. All right, so bottom line is they're asymptomatic, they're in with the screening guidelines, and they're at average risk of developing colorectal cancer. Right, so these are the guidelines for that. I think for the most part, remember that we wanna make sure to say that this was a positive screening test, right, not just Cologuard, but for any of the stool studies that we do. Number seven, how clear-cut does the reason for visit need to be for E&M? Our template puts it as a standalone line at the top of the note, but occasionally the template gets messed up and the providers don't have it on there. They're usually clear in the first sentence of the HPI, is that enough or do they always need to append it? You're right, the chief complaint or reason for visit must be clearly stated that the visit is not billable. Best practice is to have the chief complaint, but I do understand what you're saying is that we have seen that as well. The chief complaint is blank and depending upon your practice policy, some practices make the medical assistants responsible for filling in the chief complaint. Some of the chief complaints come strictly from the appointment scheduler as by the patients coming in, which explains a lot when Kristen was talking about contradictory information, right? But ultimately, ultimately, if this is blank, the provider is the one responsible for stating what the reason for visit is. And if the reason for visit is conflicting to what the chief complaint is in the top of the visit note, it needs to be corrected, right? All right, so we've been in, like I said, we get around so many different offices and we've had statements from providers saying, I can't do anything with the chief complaint. I can't get in the system, I cannot change that. So how am I gonna fix that? Well, go in in your opening statement. Chief complaint states this, but actually the patient's coming in for this, all right? That's not that difficult to do, but it has to be there. Remember what I said earlier, it's gotta be on every visit note, whether in the office or the hospital, right? So make sure that's not contradictory, make sure the reason for visit is totally clear. Number eight, my understanding on signing a consult note or any note must be within 72 hours of the service is rendered. Example date of service, 6-22-2024, 9.37 a.m. Physician consult ordered by blank MD, signed by blank MD on July 5th, 2024 at 9.36. Well, CMS specifically states signatures are required at the time the service is rendered aside from the occasional specific circumstances which would be noted in an amendment. CMS date was 5-9, implementation date was 6-10, all right? And this is, you can do the link and you can find this information. But this is exactly what it says. All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally certain entries related to services provided may not be properly documented. In this scenario, the documentation may need to be amended, corrected or entered after rendering the service. The date and author of any amendment, correction or delayed entry should be identifiable and the change addenda should be clearly and permanently denoted. Do not unlock the record, right? It doesn't say that, I'm saying that, do not unlock the record. Contractors should review any amendment, correction or delayed entry in accordance with section 3.3.2.4 of this chapter. I don't think they can be any more clearer than this. And if any of you are listening or having difficulty with your providers or any of the providers listening and saying, well, they've been telling me that, but I didn't believe them. This is the documentation. This is what they're doing. This is kind of book chapter verse. So be clear on this. Remember, legal amendment, not unlock the record. Remember what Kristen just said a little bit ago. There are breadcrumbs left in the record, right? They know when you got in, what you did, when you unlock the record and what was corrected, right? Even if it was not legally corrected. So please, I know depending on the electronic record systems that you guys have, some of you have the option where it says unlock or do an addendum. Never choose unlock, always do the addendum. Number nine, one of my providers is stating due to new guidelines regarding colonoscopy due to positive fit, the indication doesn't have to read screening due to positive fit. So you notice we've got a couple of questions in here. It only has to show occult blood in this tool. And that would be enough for us to call the colonoscopy as a screening due to positive fit. I was under the impression that the screen indication must read screening due to positive fit for it to qualify as screening. I've been making my providers addendums to update the indication to reflect screening due to positive fit, but they are getting frustrated and don't think this is necessary. Can you please give me some insight on this? And we're gonna come back. And how many times have you heard us say this already today? Best practice is for them to document screening due to positive fit. If the provider documents only occult blood in the stool, again, we can't assume it was for screening because these stool tests are also done for diagnostic purposes as well. We wanna make sure that the patient gets that preventive benefit. So it doesn't take much to just add screening in front of that. Number 10, getting towards the end here. If a patient had a colonoscopy in 2012, indication was screening polyps, recommendations was return in five years, the patient had recall for 2019 and did not come in, the patient's now in 2024, they've returned, would this be done as a screening or history of polyps? Does a patient need to have two colonoscopies with no polyps before screening can be done or since the last one was 10 years ago, is screening or would screening be the correct diagnosis? Well, couple of questions in here. First of all, what type of polyp did the patient have? Adenomatous, neoplastic, hyperplastic? If the patient has a history of polyps and most likely they were told to come back in five years, it probably was adenomatous. And I said probably, I'm not saying for sure. The physician needs to state the type, if known, specifically since we now have specific personal history codes based upon the histology. All right, so now just because a patient didn't return in five years as recommended doesn't mean this is not surveillance. If it was their choice to skip it or if something happened and they didn't come back and they just were waiting for a recall, et cetera, somebody didn't follow through and ask them why they didn't return, but it's based upon the recommendations and indications by your provider who takes in consideration the size of the previous polyps, the amount of polyps removed, the location, as well as any family history that determines surveillance protocols. And we've gotten, when I've done some meetings in offices before where there's actually not, I'm not saying a knock down, drag out on this, but there's been definite disagreements among the providers as to recalls, right? Some providers say, oh, if they've had two negative, they never have to return again, you know, but once every 10 years, and then some providers go, no. I believe once a history of anonymous polyps, they always have to follow up. So it's, again, based upon your provider protocols determine where the recall is. And we as coders really are not the ones to determine this. So one of the things you always wanna do is ask your provider, you know, you can ask this provider the same question. And I think sometimes we forget that, you know, there's nothing wrong with asking your docs because they're your best resource. They're gonna be able to give you more advice on this. And what's considered when recall needs to be done. Is it 10 years? Is it five years, et cetera? So don't hesitate on asking your physicians on this. And that was the top 10.

medical billing

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gastroenterology

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