All right, now I am going to talk about top denials in GI and how to avoid them. You know, our biggest, our most important thing is we want to get that claim out and get it paid correctly and on time. That's the best thing that we can do, but there are some denials that we get. So we need to know how, you know, what do we do with these denials? What are payers looking at? What are causing denials and how much does it cost to practice? We're going to, we're going to talk about all that. So why are your claims being denied? Many medical practices are seeing their AR climbing and cashflow declining. Okay. So we've got EHRs, claims scrubbers. Some are under the impression that the process of seeing claims and getting paid quicker has been become so much easier, but not necessarily. Okay. We still have a lot of denials that come through. Not all denial reasons will be caught through claim scrubbers, et cetera. So we basically, what that means, it may not stop in house. It may accidentally go out. All right. So what can we do to keep those denials to a minimum, minimum? And I think that's what we really need to go through in this presentation. So this is some information on how much your denials are costing you. It gets expensive. Average costs 650 to file a claim and then denied claims. I mean, anywhere from 25 to a hundred and Kathy said this earlier, it can be expensive. So what we do is we look at the EOB. We get an explanation of benefits back from the payer and it tells them exactly how they process that claim. We've got information about the payee, the payer, and the patient. What the service was that was performed, the date it was performed, the description. You have the physician's fees, you have your insurance allowable, okay? And then you have the amount the patient is responsible and then any adjustment reasons and adjustment codes or denial codes per se. So you definitely have to take a look at those, see what the denial is. And like Kathy mentioned earlier, sometimes you'll get an EOB back and it's got three or four denial reasons and you're like, oh boy. And then you call the insurance company to figure out what they want. And they're like, oh, we can't tell you how to code. So that's real helpful. So I have a polling question. True or false? I can report 45382 control of bleed if I place clips for bleeding after performing a polypectomy. True or false? False. That is correct. And that's kind of one of those denials that we get, we often see in some practices don't know that, that if you encounter a bleed and you treat it, that's billable. But if you are controlling a bleed you caused or you are just placing clips to prevent future bleeding, you can't bill that. That's bundled. And so we're going to talk about bundling issues. Modifier 59 or excess. This is our favorite denial. And I'm sure auditors, coders, billers listening in are probably rolling their eyes like, yes, we get this all the time. That's probably one of our highest denials is the payer doesn't believe us when we bill two different services. They think, oh, no, you did it to the same lesion. They request your records, things like that. So a denial will come through that says like procedure code incidental to the primary procedure, et cetera. So we always, we like to reference CCI edits. And that's because most of your payers follow CCI edits. And those are, you can Google them and download them. It tells you what codes can and cannot be billed together. And if they can't be billed together, is there a sidebar? Meaning if my documentation supports two separate sites, two separate techniques, can I bypass that edit with a modifier? Okay. And so the list is literally all of your like your procedure codes. And if they are bundled, it'll say there's column one and column two. Column two is the one that typically will take that modifier 59 or excess. So again, it's important for your staff to understand what CCI edits are and how to utilize them. Because like I said, in my previous talk, you don't want to just put a 59 on everything and hope it gets paid. So many payers request documentation when submitting two procedures. Another classic is a snare polypectomy and a biopsy. To be sure, two separate sites were actually treated by two different techniques. So providers, you got to be clear on this. You've got to document your location of lesions and your methods of removal. Okay. Don't just say biopsies. Random biopsies were taken. Where at and why are you taking them? Okay. That's one big important one. Another one, if you're treating multiple polyps, don't make a general statement such as, I found four polyps in the ascending colon and I removed them all by snare and biopsy. Again, you have to identify each polyp. I always tell providers size, location, method of removal on every single lesion. Size, location, method of removal. Size diagnosis pointers on the claim form to indicate specific diagnoses for the snare, specific diagnoses for the biopsy. So here's an example as well. So we talked about the snare and the biopsy. We also have a bundling edit in place with dilation in biopsies, so talk upper endoscopy. Providers, in order for you to build a biopsy, the biopsy has to be done outside of the dilation zone. How do I know that? You. It's your documentation. There should also be a completely separate diagnosis for the biopsy. So this is kind of more of an obvious example. So a structure was found in the esophagus, which was dilated by balloon, and an area of chronic gastritis was found in the stomach, which was biopsied with cold forceps. So you got two, obviously two clearly separate areas and two completely separate diagnosis codes. But we have situations sometimes where you might do, you might dilate the mid esophagus with the balloon, and then you might biopsy the distal or the G-junction, whatever it is. As long as you're very clear that that biopsy was taken outside of that dilation zone, then you've got it supported. So again, 8.5 and 8.0, we talked about that. We talked about making sure that there's no vagueness in multiple polypectomies. Make sure we're documenting your instrument. And then again, if you're doing like random biopsies for microscopic colitis, make sure you document where they were done and to rule out microscopic colitis is critical. It supports medical necessity. So if you send your documentation to the payer and they're like, we stand by our original decision and we're not going to pay you for the biopsy, and they follow CCI edits, here is your AMO. It's CCI chapter six, section H number 25, and it specifically reads this, the NCCI PTP with column one, 45385, and column two, 45380 is often bypassed by using 59 or the X modifiers. Use of modifier 59 or XS is only appropriate if the two procedures are performed on separate lesions. All right. So they are billable. You send this to them. Sometimes you have to, sadly, sometimes you have to print off the endoscopy report and highlight and circle for them, kind of take them back to kindergarten a little bit. So just keep appealing those. I know it's a pain, but once the payer knows, okay, they're going to fight every single one of these, they'll watch your denials lesson on this issue. So we've got some examples here. We have number one, colonoscopy with cold forceps biopsies of rectal erythema and snare polypectomy of a sigmoid colon polyp. So we can bill both. They're different, different techniques, different areas. And then, so you're going to utilize your diagnosis. We talked about the diagnosis pointer. So when you're billing 45385 on line one, you're going to point. So the diagnosis codes are kind of above the procedure codes altogether, and you can put up to 12 there. And then when you get down to the bottom and you bill out your snare, you can point to D12.5. And then for the biopsy, you can point to K62.89, which would be the appropriate diagnosis for rectal erythema. Another example, EGD with cold forceps biopsies of gastritis in the stomach and application of bleeding to a denal ulcer, modifier 59 or excess. This is actually because remember the polling question. You know, if you cause it, you can't bill it. It's bundled, control of bleeding is bundled into all of our endoscopy procedures. So if I encounter it, I'm unbundling that, I'm letting them know I didn't, it wasn't because of the biopsy I took in the stomach. So 43255 for control of bleed with your modifier, and then the biopsy would be separate and the diagnosis pointers would be specific. The ulcer for the control of bleed, the gastritis for the biopsy. Here's another one. This is for your ERCPs, ERCP with placement of a stent into the right hepatic duct and another stent, another place in the pancreatic duct. Since definition states only one stent, each can be billed as long as your documentation supports it. So you're going to build 43274 on line one, and then 43274 again on line two with a 59 or excess. Some of your Medicare contractors want you to bill 76, not a 59 or excess. So just keep that in the back of your mind there. All right. Here's another big denial reason. Modifier 25. We talked about this. Making sure that you are performing a separate visit on the same day as another service. It's significantly separate. If it's pre-scheduled, you're not billing a visit and it's not a quick visit, meet me in endo, stick my head in the door, say, hey, you ready for the procedure and walk out? That's not a visit. Hospital follow-up visits are not billable on the same day as a procedure unless something unrelated to the procedure has been addressed. Diagnosis order on the claim can be essential in avoiding these denials. So for example, in this one I'm kind of referring to like a GI bleed. Let's say a patient comes in with hematemesis, consult for hematemesis, acute blood loss anemia, then you scope them on the same day and you find a bleeding ulcer. So the symptoms can be pointed to the consult with the 25, and then the procedure would get that ulcer diagnosis. So here's a couple of examples. You've got the first one, the patient presents to clinic for plant infusion. The patient also had a separate six-month evaluation with their GI provider. The GI provider documented the status of the UC, ordered routine labs, and addressed their patient's reflux disease. That's clearly significantly separate than just walking up to the patient saying, how you doing? Number two, we see this one quite often. You do an initial visit in the hospital for feeding difficulties and you talk to the family, you go over the patient's history, and you determine that the patient would benefit from a PEG tube. All right, so that would be separate. I talked about place of service errors, making sure that you bill the correct service, place of service in which the patient received the services. I always recommend holding observation charges for a few days. Because a lot of times those observation patients will flip to inpatient. And CPT specifically states now with all the new guidelines is that the stay is reported as a single stay, meaning if the patient starts an observation, ends in inpatient, the entire visit is inpatient. So if you bill out a charge with place of service 22, the hospital flips that patient to an inpatient, you're going to get the denial and it is your error. You have to match what the hospital has. Here's just some references and links to the observation policy to ensure that, and these all change when the guidelines changed for the inpatient E&M services. So remember they kind of lumped inpatient and observation care codes together. So this is some policy on it to bill, the admitting physician should bill like the initial hospital visit cares and then subsequent inpatient or observation care, et cetera. But then all other physicians, which is typically you as a consultant, observation cares are billed by the admitting physician, all other practitioners are billing outpatient visit codes. And you're like, wait a minute. So if the patient's observation and they stay, I'm talking about staying observation the entire time, all right. And your doctor goes and sees the patient in consultation, well, they don't pay, Medicare does not pay for consults, but they are limiting those admitting, those codes, those services to the admitting provider. So we would bill those outpatient codes. And then making sure again, if it's truly observation from start to finish, that is place of service 22. Another one lacks medical necessity or lacks specificity. So print out your local coverage determinations that will tell you the diagnosis codes that are approved if they have a policy in place. Commercial payers also have many, many coverage guidelines. So check your other policies as well. Make sure the primary diagnosis submitted on the claim is specific and is supported in the medical record. Specificity is key. Providers should document and code any comorbidities and or risk factors that impact decision-making and support higher levels. Endoscopy indications must be very specific, include all specific reasons for the procedure, and you never should be contradictory. And we've said this a hundred times today, screening and symptoms. Infusion services must be documented with the specific type of Crohn's or ulcerative colitis. I cannot stress that enough. If you know the type of UC or Crohn's the patient has, please document it. All right. Especially if you're doing infusions on the patient. You should know at that point, if you put that patient on a biologic and they're in your infusion center, you should know what type of IBD they have. We made a comment about the next bullet earlier, first thing today, don't use R10.9. You're a GI provider. We should not tell the payer that I just evaluated this patient for abdominal pain and I don't know where it's at. That's what you're telling them. So that one is routinely denied. We have upper abdominal pain. We have lower abdominal pain. We have all the quadrants and we have generalized abdominal pain. Anemia unspecified does not support endoscopic procedures or capsules. Okay. So making sure that before we order those types of services, there should be an iron deficiency anemia and along with supporting labs kept in the patient's medical record to back that up because the payer will request those as well. And then we talked about this in the diagnosis coding talk. So this is the Z08, Z09, making sure your primary diagnosis code is correct because we can avoid these types of errors, right? So making sure that we're following ICD-10 guidelines. And then the excludes one note. So I gave you the list of the more popular GI codes that cannot be billed together. That's what an exclude one is. And the denial will come back as invalid diagnosis code pairing. Here's part of that list that we went over in the ICD-10 talk. So I'm going to just quickly go through them because we already looked at those. Closing remarks. Never assume a denial is due to a coding error. Always research the reasons on the EOB. Never write off the claim for the first denial unless truly was an error in submission. Research and resubmit. Never accept the payer's initial review as final. Go further. Again, involve your providers. Go to the medical director. Utilize tools to support your medical necessities such as LCDs, CCI policy, everything we just went over. Utilize them. They're at your fingertips. And always involve your patient in the appeal process. And that is it for that talk. So it looks like I'm going to hand this over to Kathy, and she's going to talk about medical necessity. Thank you.

GI claim denials

billing errors

coding modifiers

documentation

National Correct Coding Initiative