There's a tremendous amount of information. We're going to come together. I'd invite all the panel members to turn on their cameras. We're going to do our Q&A session, and we are running a little behind, so we'll keep it tight. Okay. We're going to jump all the way back to a discussion on colorectal cancer screening, specifically with some special scenarios. So if a patient who's under 45 years old, but has a family history of Lynch syndrome or AFP, no personal history of polyps, how would you consider this colonoscopy that you're doing? Is it diagnostic? How could it be screening? What specifically would need to be documented and built? Well, I'm glad that you said family history, because a lot of times, all we see is Lynch syndrome. So when you look at Lynch syndrome, that code is Z15.09, and it pretty well means genetic susceptibility. And even so, it doesn't necessarily say it has to be ... It's not a primary diagnosis. It usually is not considered a primary diagnosis. All right. So does the patient have a personal history somewhere? Do they have a family history? That's very important. And because this is considered high risk ... Here, I'm going to turf this to Dr. Littenberg, as well as Dr. Sun on this one. When do you start a patient on screening for these conditions? It can be as early as teenage years with adenomatous polyplosis coli, APC. But it kind of depends whether the individual has been tested themselves, has a susceptibility gene. Sometimes we have a family history, no genetic testing. We think the patient's at a high risk. So it could be anywhere early in years until later, 20s, 30s, 40s. But they're still considered by us at high risk and warranting screening. If they're asymptomatic, it is screening. It's not surveillance, but it is tricky and some payers handle it one way, some handle it another. Then it wouldn't be considered diagnostic either. Let's talk about a patient who's under 40 coming in with a family history of colon cancer. Is that family history of colon cancer legitimate if it was a second degree or third degree relative or is it specifically only for first degree relatives with colon cancer? That's payer policy, unfortunately. Some of them go by ASGA guidelines. Some of them don't. Medicare says first degree relative and they don't even give you ages. So again, this is completely up to documentation by the physician as to why are you doing this? When did it start? And then we have to do reauthorization to verify eligibility to whether or not this is a covered benefit for that patient. And we are seeing so many problems. Even though your documentation supports the need for screening at an early age, we've got some payers that won't cover it. So because most of this is elective, do you want to fight and make sure the patient gets this benefit beforehand? So again, I think our providers definitely have to be aware whether or not this payer is going to cover it. And the only way that we're going to know this is to verify eligibility at the time of preauthorization. So like I said, it's that second step that is vital. So if that payer goes, no, we're not going to cover it, our policy won't cover it, then it goes back to our provider or whoever's ordering it to either potentially do a letter or get on, you know, talking to a medical director or, you know, sometimes what I would do when I worked in the office, if I would get feedback from the preauth department that says they weren't going to cover it and my doctor was standing by, I hand the phone to the doctor. All right, I just hand it to him and say, hey, they're not covering it. And he'd get on there and miraculously they start, they sputter and they do everything and they end up getting it approved. All right. They just back down. So I think sometimes that's your best resource if you have the ability and your doctor's standing there and you can just hand him the phone. But I think this is something that you really need to go back to your providers before you end up doing this. Because once, unfortunately, if you don't go through these steps and you do that procedure, it's done. It's a done deal. Great. Okay. We're going to talk about EMR. This has come up quite often. What actually counts as EMR in terms of demarcation? I'm assuming the question about underwater EMR without injection is really a question about is demarcation then demonstrated with this technique? If you document this, can you then say that the outline was, you know, that demarcation was performed? This, yeah. We've had a question. Actually, we've had a couple of vendors bounce this off of me as well. What do you, you know, is this considered an actual EMR if it's done underwater? And for those of you that have not seen this technique, Google it. Just Google how it's being done because it's really kind of cool. If the payer's a stickler that they're, if an injection's not done, they may not give it to you. All right. But I think your documentation in there, I consider that an EMR. And I pretty well advise the practices to go ahead and build that as an EMR. And if there's any problem with that and they do a review, then we can do a response. I mean, what is your information? What do you guys think about that? Yeah. I agree. I think it's, if you document all the steps that went into this, why this was a more involved procedure than just a, you know, a regular polypectomy. It's all about your documentation and being able to justify that level of billing. Yeah. I mean, it would be nice if you put a comment in the procedure report, if you're doing it underwater. I think the endoscopic lift was not clinically necessary after viewing the lesion underwater and could proceed with the specialized snare polypectomy, whatever method you use for removal. I think it's still justifiable as EMR. You know, another question that comes up often about demarcation, can using just white light endoscopy suffice? And if you look at the actual language of what's entailed in demarcation, yes, white light endoscopy, as long as you're deliberating the borders of that lesion, that counts. But I would state specifically that demarcation was important and that you can bill for an EMR. A statement like the lesion was well demarcated by white light or NBI light microscopy or colonoscopy imaging. Anything could indicate that. The more specific you are that way, the better off, at least your procedure is defensible if it comes under question. Yeah. A few questions about unlisted codes. So we typically, we sometimes place clips for endoscopic tissue marking location. Is this billable? And it's my understanding that there are no specific CPT codes for endoscopic tissue marking with a clip. So you might be able to try using some unlisted codes depending on the location of the clip placement, such as if it's in the intestine, 44799. But I really haven't seen much success with this, Kathy, Kristen, Glenn. Yeah. Clip unfortunately, even clip placement is part of any type of polypectomy you do as well. But yeah, just to place it, unfortunately, it's just considered just a standard EGD or colonoscopy. Yeah. And like you said, if you do decide to bill it as an unlisted procedure, we have not seen, even the colonoscopy, we really haven't seen a lot of success getting the practitioners paid an additional amount of money other than the base code. Yeah. What about double balloon enteroscopy? What code should be billed here? It's my understanding that if it's anti-grade, you could either use 44360 or 44376. If it's retrograde, then I would use the 44799 unlisted procedure. Yep. Correct. Okay. That's it. And you can use a comparison code of the uppers for that, to do that. I know at one time, years and years ago, they actually, CPT did have a code for the double balloon retrograde, but never went through. It would have been nice. It was based on centimeters. Yeah. Continuing with unlisted codes, what about endoscopic vacuum therapy? So this is where, let's say there's a leak or perforation of the esophagus. The endoscopist inserts a sponge connected to a vacuum. That over time helps with secondary intention healing and then closure of the actual defect. Best advice I could give is to use an unlisted code 43499. I don't know about the comparable codes though. There is a surgical code 43405, which is a provider closes the esophagus with staples or sutures and inserts a feeding tube into the stomach or jejunct, but I'm not sure what comparable code we could use for. That's kind of what I use, what I pretty much tell them to do. It's an esophagoplasty code. You can use any one of those in there, but it's a repair and that's the best comparable code to use, the 43405. The 43499 for the unlisted, and we do see this more and more. We see this on the pediatric side too. So the kids with esophageal atresia and they've had repeated reconstruction and they still end up with a fistula of some sort. So they're doing it to heal by kind of a secondary intention on there and it works very well. It definitely beats an opener thoracoscopic approach. There's a question. We're getting denials. Now this is going to be potpourri. We're getting denials on 76981-26 due to place of service. We are hospital based in terms of location. Any suggestions? That's the elastography code. Yeah. There is no restriction on that code for the place of service. 91200 for the without imaging has a restriction on the place of services, outpatient hospital or ASC, but it shouldn't on that. So I'm just wondering if there is another denial reason. I have a feeling it's probably due to a diagnosis code. Do you think it has anything to do with the technical component being billed in a different place of service or anything? That's possible. Because it's a hospital owned. Did the hospital bill it as global and not only, or just with the TC modifier? Yeah. There's a couple of different potential issues there. That's quite likely to me. We could direct individual site-specific questions maybe to our ASC coding, or our coding center, and then we can help with that after the course. Can you bill Z1211 as the primary ICD-10 code for surveillance colonoscopy, if you document surveillance? All right. So this is going to be payer-specific, and also state-specific, like what I said before. We do have, I had put a UnitedHealthcare's policy up there, but within UnitedHealthcare's policy, if you go on individual, either patient-specific or employer-specific, sometimes they will allow the preventive benefit for somebody that has a history of polyps or history of cancer, and will allow you to put the Z1211 in front of the Z86 codes, or the Z85 codes. So it's a possibility, as long as you've got written documentation to support it. Okay. Let's go to our next question. If a patient came in for screening, and polyps are found and pathology is done, how can we be paid in full for commercial plans? Can we add a screening code in the pathology itself? This is a question about getting paid for the pathology. Right. I know I mentioned this just in the last presentation. The screening, the Z1211 in front of a polyp code for PATH can cause a problem with several payers. Some of them don't want the Z1211 in the first position. Medicare has no problem with it. Medicare replacement plans do not, and neither does United. Actually, United has, on their preventive codes, they have a list of what's considered a payable diagnosis, but those are three I'm telling you about. Not all of them follow those guidelines. So it doesn't make sense for a pathologist to bill Z1211 when they were looking at a specimen. Right. What's the final diagnosis? So if the payer will not allow the Z1211 in the first position, you can use it in the second, third, fourth position, or you can use the common field box 19 and actually enter in was a screening but converted to polypectomy to see if that would help. And last but not least, even if that doesn't work, then you're going to have to get and talk to them and appeal it and show what the Affordable Care Act says. Great. If several family members come and they have several family members have adenomatous polyps, but they're not cancer, let's say they're even high risk polyps, that's ulcerated, is the individual still considered to be increased risk and can start screening early and get coverage? And then can you do it every five years? Okay, doctors, what's your opinion? If they're polyps and not cancer, I don't think that would qualify. Glenn? It kind of depends how much info you really have. I mean, how often do we really find out a family member has an adenomatous pulse? That's hard enough to find out. And then it's, you know, age related. So I mean, I would consider them high risk, potentially, to try to justify doing them more than every 10 years, even if they were negative, if you really had pretty confirmable data, early age onset, unfortunately, we're often lacking that information. And then it'll potentially depend on each, you know, on an individual payer, what they do with the information. Yeah, yeah, I agree. So we do have a number of questions left. However, we've gone completely through our break time and lunch. What I would ask is we take a 10 minute break, if people can get their lunch and continue eating while we're actually continuing the presentation, I'd really appreciate that.

colorectal cancer screening

coding and billing

underwater EMR

preauthorization

documentation