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

Pdf Summary

This presentation by Kristin Vaughn, a healthcare consultant and lead auditor, addresses critical compliance issues faced by medical practices related to Recovery Audit Contractors (RAC), Office of Inspector General (OIG), and other governmental entities.

Key topics include:

1. <strong>Incident-To Services:</strong> Defined by CMS, these require a physician to perform the initial evaluation and establish a treatment plan, with follow-up services by non-physician practitioners (NPP) under direct physician supervision in a non-institutional setting. Proper documentation linking NPP services to the supervising physician and adherence to supervision rules is essential for compliant billing under the physician’s NPI, which affects reimbursement rates.

2. <strong>Modifier 25 Usage:</strong> It allows billing a significantly separate evaluation and management (E/M) visit on the same day as a procedure, provided the visit is distinct and documented properly. Examples illustrate correct application to avoid denials, including linking diagnoses appropriately to the consult and procedure.

3. <strong>Improper Use of Provider NPI Numbers:</strong> Billing under another provider’s NPI is prohibited except under specific circumstances like incident-to billing or locum tenens. Practices must ensure accurate NPI use to avoid false claims.

4. <strong>Unbundling of Services:</strong> Highlighted through CMS’s multiple endoscopy policy, which allows payment for separate procedures on distinct lesions using different techniques with appropriate modifiers. Documentation of lesion specificity and procedure technique is crucial to prevent denials.

5. <strong>Medical Necessity and Documentation:</strong> Emphasizes that documentation must support the billed level of service, particularly for high-level E/M codes often audited. Diagnosis codes should align with documented findings and treatment plans to avoid downcoding and audits.

6. <strong>Signature and Timely Documentation:</strong> CMS mandates legible authentication of records via hand-written or electronic signatures. Late signatures require attestation. Documentation must be completed promptly to ensure accuracy.

7. <strong>Risk Adjustment Diagnosis Coding:</strong> OIG flags inappropriate or unsupported diagnoses that may lead to improper payments. Accurate, specific coding and documentation are vital.

8. <strong>Commercial Payer Auto-Downcoding:</strong> Cigna and other payers have implemented policies to downcode visits not meeting AMA E/M guidelines, affecting reimbursement. Providers should verify documentation and appeal improper downcoding.

9. <strong>Responding to Audit Requests:</strong> Practices must respond timely and thoroughly to RAC, OIG, CERT, and other audits, providing complete legible documentation without altering records.

10. <strong>Conducting Internal Audits:</strong> Regular, credentialed audits—prospective when possible—help identify and correct errors, avoid improper payments, and improve provider documentation and coding practices.

Communication among billing, coding staff, and providers is underscored as critical to compliance and correcting issues promptly.

The presentation provides practical guidance for healthcare providers to navigate regulatory audits, maintain compliance, and optimize accurate billing and documentation.

Asset Subtitle

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

Keywords

Incident-To Services

Modifier 25

Provider NPI Numbers

Unbundling of Services

Medical Necessity

Documentation Compliance

Risk Adjustment Coding

Commercial Payer Downcoding

Audit Response

Internal Audits