I think we've kind of stressed this one pretty well all day, too. Documentation has to support medical necessity. Whether it's a visit, whether it's a procedure, this is one of the things that the payers are looking at. So overall, medical necessity is your key to economic success. We're going to talk about medical necessity per EMM, just an overview, the principles of medical record documentation, and also some endoscopy tips. I think you pretty well know, if you don't have medical necessity, you won't get preauthorization. And we've been talking about this, too, making sure that payers require preauthorization for endoscopy, CT scans, MRIs, capitals, et cetera. You can get recouped of previously paid services. We are looking at the commercial payers who will routinely do, it's actually based upon their requirements, that they have outside auditing at least every three years to make sure that they are paying claims appropriately. And then we have Medicare replacement plans that are also mandated every two years to have an outside auditor to make sure that they are following CMS and paying claims appropriately. This is sometimes where we see recoupment take place when the outside auditors come in and review the services. Top medical necessities for payer focus, diagnostic EGDs, infusion services, hemorrhoid treatments, multiple endoscopy, pathology, screening versus diagnostic, and E&M services. Pretty well everything we've been talking about so far today. So let's talk about E&M services. We have seen that diagnosis codes can trigger a pay down, a payer down code. You know, so if somebody's coming in with GERD and you're submitting 99214 on the claim, but actually other diagnoses or conditions were addressed and not submitted, that can get you a down code. And if you receive multiple down coded claims, this can trigger an audit. And we also look at providers in the group. So if one provider in the group is considered an outlier, this can actually lead to an audit for the entire practice. And we've seen practices get into audit situations just because of this. Making sure that you pay attention to the core elements of the E&M service. And the core elements now are the HPI and medical decision making. We were just within a practice the other night that had a new provider come in and, you know, he's like, oh, you mean I don't have to do four months of the HPI and a 10 or 12 system review or evaluation in the hospital anymore? No, you don't. All right. But you do have to make sure that the history of present illness is well documented, but the routine elements of the history and exam should be pertinent to the chief complaint and what you're addressing. But the thing is, is the payers are auditing your practice by your decision making requirements, right? Compare that the diagnosis code submitted, support the assessment and plan, and then decision making versus time. You know, making sure your provider fully documents everything done in the encounter and focus on the impression and plan. And avoid using pre-populated problem lists. We have seen this too often. A problem list just goes in there and there's 20 things. Well, yeah, 20 things that you've treated the patient for over the past 10 years. All right. In the hospital, oh my gosh, this is what we're seeing. In the assessment and plan, there's 20 things. Well, infectious disease, pulmonary, cardiac, all are all managing some of these other problems. You only address what you are managing. Don't muddy the waters. Just make sure that you're addressing what you're managing. You know, if decision making doesn't support the level, use time to support your billing. All right, so what are the principles of medical record documentation? Number one, it should be complete and legible. And Kristen made that statement. We don't see a lot of handwritten records anymore. And you're right. We do see a free anesthesia, but unfortunately, if it's not legible, it's not billable. The definition of each patient encounter should include the reason, the assessment, the plan of care, and the date and legible identity of the observer. That means, obviously, we need to have a signature. If you have initials on there, if you actually have a signature that's not legible, every practice should have a list of providers with their corresponding initials and signatures so that anybody that comes in that's looking at a note and can't figure out who signed it can have a list. And always give that to the auditors at the time if they're coming on site to review. If not documented, the rationale for ordering diagnostic or other ancillary services should be easily inferred. All right, making sure that's clear because preauthorization is key. All right, and the ones that are left to preauthorize are your staff, and they have to know exactly what's being done. Guess what happens? If they can't figure it out, preauthorization will not be obtained. Past and present diagnoses should be accessible. Appropriate health risk factors should be identified. We were talking about co-pays, not, I'm sorry, not co-pays, comorbidities, risk factors. Patient's progress, response to, and changes in treatment and revision of any diagnoses or conditions should be documented. The CBT and ICD-10 codes reported on the health insurance claim should be supported by documentation in the medical record. We've actually heard some horror stories on some of this stuff. So for instance, well, we know that D64.9 will not be approved for the endoscopy. But if we add D50.9 to it, a claim will be paid. But iron deficiency anemia is not documented. But if you add the diagnosis code, it'll be paid. It's got to be in there. It's got to be substantiated. You just can't make up a code just to get a service paid. List the diagnoses and conditions in the assessment and plan and the ordinance of importance, and I mentioned this earlier, and the highest degree of specificity. Kristen just identified location of abdominal pain, location of IBD, specific as to liver enzymes. All right. Yeah. There's some weird codes in ICD-10 that really don't apply, but, you know, and it can lead you to the wrong, what's the, sorry, the wrong code. Abnormal elevated transaminase, lipase, amylase, bilirubin, be specific, right? Be specific as to which lab tests and diagnostic studies are ordered. Because remember, and Dr. Sun went over this earlier, you get credit for every panel test that you do. So if you just say I'm ordering labs, guess what? You get nothing. But if you say you order a CBC, a CMP, an INR, that's three points. All documentation must be signed or it isn't a legal binding document. And last but not least, most important, one of the most important things is every visit must have a chief complaint slash reason for visit. That includes every visit, every new patient, every follow-up, and yes, in the hospital as well. I think one of the things that we see on the hospital side on follow-up visits is we do not see a chief complaint. All right. So the provider's role of the assessment and plan, it should be clear, include any details. Do not code from a problem list, I just mentioned that. Include comorbidities and risk factors, and it should show evaluation and treatment of each condition that relates to an ICD-10 code. Sometimes we see just a copy and paste, copy and paste, copy and paste for everything. It should be specific to each diagnosis or condition that you're managing. All right. So a lot of times we see that some of the providers just sell themselves short of their hard work. The conditions may be addressed and treated, but it doesn't go into the assessment and plan. You know, it is acceptable to include history of conditions if it affects the current treatment, but if there's a history of colon polyps and the physician orders a surveillance colonoscopy, remember that history of means the patient no longer has that condition, and it should be coded with history of, and we see this with cancer. So we see colon polyps. Does that mean the colon polyps are still in there? Mm-mm. All right. If you assign the diagnosis of colon polyps, that means they're still there. If you sign history of colon polyps, that means that they're gone. All right. So sometimes it's very hard to find that diagnosis code because if you don't, let's put it this way. If you type in history of to find that code, you're going to get the actual code. The only way that you're going to find history of is to type in personal history of, and that will get you to the right Z code. Otherwise, just history of gets you to an actual code. All right. Endoscopy billing tips. You can't bill for more than one polyp or lesion removed by the same techniques. All right. We talked a little bit about modifier 22 earlier. We can bill for each technique utilized to different lesions. Kristen gave you that documentation to support that. It was CCI policy chapter six, section H, number 25. All right. That's where you're going to find that information. All right. Make sure that the instrument used to biopsy is documented. Make sure all your instruments used are documented in the endoscopy reports. If your endorider sends you, you know, it's kind of a hard stop. It stops you at location. You fill in the blanks. It stops you at technique. You put the instrument in. Do not just scatter through that. Just make sure and fill in the blanks on this. Right. Otherwise, it can cause surfaces to be overlooked and money potentially to be recouped. Make sure that the billing staff should utilize CCI edits or claim scoping software. A lot of your EHR systems or your, I should say, billing software does have that feature built into it, but if it does not, then they should be able to get that easily at their fingertips and coding software is, I'm going to tell you, it's valuable and it makes you much, much more efficient. Medical necessity for EGDs. Since 2018, when Anthem started doing pre-authorization for EGDs, a lot of the other payers have joined in. You know, let's follow the leader on some things. So upper signs and symptoms, GE reflex symptoms that persist or recur following an appropriate trial therapy for two months or more is approved as medically necessity for EGDs. That wonderful statement, GI quick, all right, it's a quality measure, all right, is often put in our upper endoscopy indications. That tells me nothing. There is no ICD-10 code for GE reflex symptoms. It doesn't mean the patient has GERD. It just says they have symptoms of GERD. What are the symptoms? Document them. I cannot stress enough that on upper GI endoscopy, all symptoms pertinent to the reason why the EGD should be listed. Pertinent vomiting, new onset dyspepsia in individuals 50 years of age or older, dyspepsia. I don't like that term. There's a diagnosis code for this and actually potentially two. K30 means the patient has dyspepsia because we can't find a source. We're just going to assign it. Dyspepsia also gets potentially assigned a code of R1013, which is epigastric pain. That doesn't have an age limitation. I would recommend you using the term epigastric pain over the term dyspepsia. Unexplained dysphagia, adenophagia is covered. Signs or symptoms suggesting structural disease of the upper GI tract. All right, don't stop there. Give me the symptoms. Postoperative bariatric surgery with persistent abdominal pain, nausea, or vomiting, a recent or active GI bleed. These are all indications. Unexplained anemia due to either blood loss or malabsorption. Again, not unspecified anemia. Confirmation and specific histologic diagnosis of radiologic demonstrated lesions. That diagnosis code is R93.3, abnormal imaging of the GI tract. If you just say abnormal CT of the abdomen, that code is R93.5, and that is not approved. You're usually scoping because of abnormal imaging of the GI tract, so try and use that verbiage over abdomen. Documentation of esophageal varices in individuals with suspected portal hypertension or cirrhosis. All right, rule out varices, screening for varices. That's not the appropriate indication. Why are you suspecting the patient has varices? Because they have underlying cirrhosis. So cirrhosis is the indication, cirrhosis, screen for varices, that's the term you should be using. All right, I'm going to skip some of these. EGD with biopsy is bundled into any esophageal dilation code unless the biopsy is outside of the dilation zone. I just kind of answered one of those questions earlier. So your providers need to specify the exact location that was biopsy. If the guidewire dilation is done, often that encompasses a good majority of the esophagus and the biopsy would be considered part of that dilation. So in order for that to be done, the biopsy, again, would have to be outside of the dilation zone. It is solely up to the physicians to document the exact locations, right? If the biopsy is in the stomach or the small intestine, then that's easy. That's definitely outside of the esophageal dilation area. Biopsy is also bundled in several ERCP codes with sphincterotomy, stem placement, dilation, et cetera. So again, be specific as to the site if it's outside of those zones. Remember to specify differential diagnoses. We talked about double balloon enteroscopy earlier, right? EMR, we talked about endoscopic mucosal resection, making sure that the documentation and that terminology be utilized. Incidental dilation, which is dragging of the balloon during an ERCP, is considered part of an ERCP and is only billable, the removal of stones is billable if sludge or debris is removed in addition to stones. If there was actually a strictured area that had to be dilated, that is separately billable. That will require the 59 modifier or the excess modifier to indicate this was not an incidental dilation. And doctors, you really need to document this much more specific as to exactly where this area is. Otherwise, it kind of looks like it's incidental. We just dragged the balloon, did the dilation. We can't bill separately for that. Each stent is allowed to be separately billed, right, during an ERCP. So make sure that you document the location of each stent. The spyglass, otherwise known as cholangioscopy, is billable during an ERCP repeat procedure. All right, so please make sure that you're documenting that as well. This is another one. Yes, you can bill for the interpretation of biliary and or pancreatic duct images during ERCP, as long as there is documentation to indicate that you personally interpreted the images. There is a static image kept on file, and there is no conflict with the radiologist who could also be billing for that same interpretation. So yes, you can bill it, but there definitely are strings attached to this. And your documentation in the ERCP report should say, I personally interpreted the bile duct images without assistance of the radiologist and list interpretation. And usually, I would recommend you put it in a separate paragraph in the ERCP report. When banding or treating hemorrhoids, anoscopy is included and not separately billable. And no matter what you do, no modifier will bypass this edit. Control and or prevention of bleeding, and this is in caps. I should highlight this. I should make this in bold. It's bundled into every procedure and can't be billed unless it is a separate site or lesion. And if you do have a separate site or lesion, say you have a bleeding ABM and you did a polypectomy in another area, the 59 or the excess modifier, which means I'm not bundling, this was a separate site, always gets added to the control of bleeding code, even though that may be the better reimburser. Remember, Kristen said this earlier, no common sense associated with billing and coding. You would think that that would, you know, the more expensive procedure would not take the modifier. But remember, it's always the bundled procedure that takes the modifier when you can prove that it was in a separate site, separate lesion. All right. Already talked about unlisted procedure codes, making sure you have a separate cover letter to explain the procedure. Useless symptoms which require diagnostic evaluation and differential diagnoses. Remember that your pre-authorization staff rely on the specificity of your documentation, not specific. You can get your patient care directly impacted, delay in treatment, not good. Again, make sure all pertinent comorbidities are listed. And all specific indications are listed on your endoscopy report. Documentation is completed and signed in a timely fashion. And remember, as soon as it's done, based upon the latest CMS guidelines. Keep up to date on all payer policies, share with all providers. All right. And last but not least, I can remember that. That was part of my training during school. If it wasn't documented, it wasn't done. All right. True or false. The computer at the payer looks at the CPT code on the claim to determine medical necessity of the levels. It's pretty, okay. It's actually false. All right. They are looking at the ICD-10 codes to determine medical necessity. All right. You may have a level five in there, but if your diagnosis code doesn't support it, our codes don't support it. That's what's going to get you pulled into a review situation. Okay. Thanks, guys. And next on the agenda is back to Dr. Littenberg, and he's going to talk to you about the other E&M.

medical necessity

documentation

diagnosis codes

payer audits

ICD-10

compliance