2026 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2025-Top OIG, RAC and other Alphabet Agency Issues

Video Transcription

Video Summary

The video discusses current focus areas for OIG, RAC, and other audit agencies targeting healthcare practices, especially in GI services. Key audit topics include compliance with incident-to guidelines, proper use of modifier 25 for significantly separate same-day visits, avoiding improper use of provider NPI numbers, unbundling procedures like multiple endoscopies, and ensuring medical necessity and documentation support service levels. New areas of concern include risk-adjusted diagnosis coding and commercial payer audits that often result in automatic downcoding of evaluation and management (E&M) visits.<br /><br />Incident-to services must follow CMS rules, requiring direct physician supervision and being limited to office settings. Modifier 25 claims require documented, distinct evaluation beyond the procedure. Improper billing under another provider’s ID or unbundling without adequate documentation leads to denials or audits. Documentation must specify procedure techniques and diagnosis codes must support visit complexity to avoid downcoding or recoupments.<br /><br />The importance of timely, authentic signatures and real-time documentation is stressed, as delays can jeopardize compliance. Risk adjustment coding errors can trigger audits due to unsupported high-cost condition codes. Commercial payers like Cigna have begun automatic downcoding, emphasizing the need for correct documentation and appeals when appropriate.<br /><br />Providers should respond promptly to audit requests with complete records, consult attorneys for complex reviews, and conduct regular internal audits with ongoing staff education to prevent issues and reduce audit risk.

Asset Subtitle

Kristin Vaughn, CPC, QMC, QMGC, CPMA, ICDCT-CM

Keywords

OIG audits

RAC audits

incident-to billing

modifier 25

provider NPI misuse

unbundling procedures

risk-adjusted diagnosis coding