2027 Gastroenterology Reimbursement and Coding Update (Virtual) | November 2026-OIG, RAC & Friends-Navigating the Compliance Alphabet

Pdf Summary

The presentation reviews Medicare audit and compliance risks affecting gastroenterology practices, emphasizing that coding and coverage rules change and providers should verify current CMS and payer requirements.<br /><br />It distinguishes major audit programs: Recovery Audit Contractors (RACs) identify improper payments, generally through retrospective claims reviews; Unified Program Integrity Contractors (UPICs) investigate suspected fraud, waste, and abuse and may impose payment suspensions or refer cases to law enforcement; Supplemental Medical Review Contractors (SMRCs) conduct nationwide post-payment reviews; and the Targeted Probe and Educate (TPE) program combines focused claim reviews with provider education.<br /><br />Common GI audit targets include modifier -25 for separately identifiable evaluation and management services, modifier -59 and X{EPSU} use for distinct procedures, place-of-service accuracy, colonoscopy frequency and surveillance documentation, medical necessity, and infusion drug units and diagnoses. Auditors may also examine procedure volumes, repeat procedures, endoscopy coding patterns, and relationships involving ambulatory surgery centers and referrals. Repeated or systematic errors may lead to extrapolated overpayments and more serious enforcement consequences.<br /><br />The presentation also outlines compliance requirements for incident-to and split/shared billing, including appropriate physician involvement, supervision, documentation, and applicable setting rules. Claims must connect supported diagnoses to the services provided and meet relevant coverage policies.<br /><br />To prepare, GI practices should assess their highest-risk providers and services, analyze billing and denial trends, establish a workplan for prospective and retrospective audits, use consistent review methods, educate staff, implement corrective actions, and document follow-up monitoring. Regular internal review can help identify and correct issues before they escalate.

Asset Subtitle

Kathleen A. Mueller, RN, CPC, QMC, QGMC, CCS-P, ICD-10 Proficient

Meta Tag

Concept Medical Necessity

Concept Recovery Audit Contractor

Concept UPIC

Concept OIG

Concept Diagnosis Pairing

Keywords

Medicare audit

gastroenterology compliance

coding rules

CMS requirements

Recovery Audit Contractors

Unified Program Integrity Contractors

Supplemental Medical Review Contractors

Targeted Probe and Educate

modifier 25

modifier 59

Medical Necessity

Recovery Audit Contractor

UPIC

OIG

Diagnosis Pairing