So, it gives me great pleasure to introduce the Gene and Lynn Overholt Endowed Lecture. The Gene and Lynn Overholt Endowed Lecture is presented by the ASG Foundation through generous financial support from friends and colleagues of Dr. Gene Overholt and Mrs. Lynn Overholt. A past president of the ASGE and recipient of the Rudolf V. Schindler Award, Dr. Overholt's many accomplishments include the development of the flexible sigmoidoscope in the early 1960s, an innovation that paved the way for flexible colonoscopy. With his groundbreaking research into photodynamic therapy and laser-induced fluorescence, Dr. Overholt helped lay the foundation for today's endoscopic therapies for diseases like Barrett's esophagus and esophageal cancer. Today's inaugural Gene and Lynn Overholt Endowed Lecture will be delivered by Dr. Edward Sun, and it's titled, Better Billing in Gastroenterology and Endoscopy. This talk honors Gene Overholt's pioneering work in practice management, as he was instrumental in moving GI endoscopy from the hospital environment to the ASC setting with the creation of the first Medicare-accredited ASC. Realizing the need for physician involvement and leadership in success of their practices, Dr. Overholt established the first GI Outlook practice management course in 2005. It's my great pleasure to introduce Dr. Sun. Ed is the ASGE CPT advisor to the American Medical Association, representing GI at the AMA CPT panel meetings. He served on the ASGE Reimbursement Committee since 2015, and he is a staunch advocate for advancing GI payment and reimbursements. On a personal note, introducing Ed today is particularly special for me, as I've watched him grow and flourish from the time he was a resident at Stony Brook, a chief resident at Stony Brook, a GI fellow at Stony Brook, faculty member who went on to earn his MBA from the Wharton School of Business while he was a junior faculty member, an assistant CMO at Stony Brook, and then his relatively new leadership position in the Northwell Health System. Sorry, Ed. Sorry, because we miss you. Please join me in welcoming Dr. Ed Sun for delivering this important endowed lecture. JB, thank you very much for that kind introduction, and thank you to Dr. Asombang, Dr. Calderwood, and of course, Dr. Buscaglia for inviting me to talk to you today. I actually had the privilege of speaking with Gene Overholt a week ago. What a kind gentleman. He's 87 years old. Still took the time to review my slides and give a stamp of approval. He also said, it is so important to grow your practice and to grow your profits because then you can do more, and then you can take better care of your patients. And it's worth repeating that there is nothing wrong, there's nothing selfish about maximizing your reimbursement appropriately if you're able to do more for your patients, if you're able to take better care of them. So with that in mind, let's get into it. I have no disclosures. I'm going to talk about the physician fee schedule. We'll break down evaluation and management visit rules. We'll talk about social determinants of health, ICD-10 codes, and how that can actually help you with medical decision making. We'll talk about split shared billing tips, billing coding and documentation tips for advanced procedures, and finally, this HCPCS code, G2211. Reimbursement for skilled nursing facilities, hospitals have all gone up with inflation. As the consumer price index, or the CPI, goes up, it's a marker for inflation, so have practice costs indicated by the Medical Economic Index, or MEI. But physician reimbursement has not. In fact, in 2024, as practice cost inflation in the MEI continues to increase steeply, physician reimbursement has stayed flat, if not decreased. Instead for inflation in practice costs, Medicare physician payment declined 29% from 2001 to 2024. So how do we get paid? Well, we get paid with total RVUs, which is a component of work RVUs plus practice expense plus malpractice, which is then adjusted by geographic practice cost index. And the payment is your total RVUs times a conversion factor. So the work RVUs, actually, when we talk about payment, that conversion factor is the most important thing. And the conversion factor for 2024 is $33.29, which is a decrease of 1.7% from calendar year 2023. I've mapped the conversion factor out since 2020, and it's a straight line down. And if I'm giving this talk next year, I guarantee that that conversion factor is going to be at least 32.69. So as you can see, reimbursement is decreasing, and costs, your costs of capital expenditures, human resources are all increasing, there's a tremendous pressure for us to do more procedures and see more patients. That's why now more than ever, it's important for us physicians to understand the basics of coding and billing, and to stay abreast of changes in coding, documentation, and reimbursement rules. So my goal today is really twofold, to help you bill accurately to receive full payment, and to bill effectively to make more for the work that you're doing. Get the credit that you deserve. And of course, avoid any unforced errors. So we all remember the time when you had to determine your level of billing by having 10 review systems, eight physical exam elements, and it was bean counting. Well, those days are gone, right? Everybody knows that. In 2021, those rules went out the window for outpatient work. In January 2023, the same rules applied to inpatient work. You still need to include a medically appropriate history and physical exam. But now you're going to determine your level of billing by two factors, medical decision making and time. Here's the first unforced error. So many of our EMRs are still macroed up to include a complete physical exam and all of those review systems. But if you're writing and you're checking the box that the patient is well developed and well nourished, and you're seeing a cachectic patient for a PEG tube consult, that claim is going to be denied. So you have to be very careful with what you're including now in your physical examination or what your fellows are including on your behalf. So that was the why, and now we're talking about the what. And we're talking about medical decision making to help determine your level of billing, and it's distilled into three factors, and I call them PDR. The number and complexity of problems addressed at your encounter, D, the amount or complexity of data reviewed and analyzed, and R is risk. Risk of complications and or morbidity or mortality for patient management. So PDR, and the rule is best two out of three. So if you have a moderate number and complexity of problems addressed at the encounter, a moderate amount of data that you've reviewed and analyzed, but a low risk of complications, you can bill a moderate level of MDM, and I've included the E&M codes for outpatient office visits, initial visits, subsequent visits, and the inpatient hospital codes as well. I don't expect anybody to read this, but this is the official guide from CMS with regards to how to determine your level of billing. In the next three slides, I break it down simply into a cheat code for you. So these cheat sheets are very helpful. If you have a patient who's not at his or her treatment goal, they're not stable, even if the condition hasn't changed and there's no short-term threat to life or function. As far as I'm concerned, as consultants and gastroenterologists, we shouldn't be billing level one. That's out the window, and we should minimize our billing of level twos. In order to get to a moderate, you only need one undiagnosed new problem with uncertain prognosis. That's your patient coming to see you with abdominal pain, and in order to get to a high, if you're seeing a patient and sending them to the ED or to the hospital, that's an acute illness that poses threat to life or bodily function. But for your patient with ulcerative colitis who's had an exacerbation in their rectal bleeding, they're coming to see you in the office, that can count as a high in terms of problems addressed. Let's talk about data. The difference between moderate and high in terms of data is just with moderate, you only need one out of these three categories, and high, you need two out of these three categories. Well, category one, we all do this. We review old tests, prior documents. If you have a patient who comes in and they're not able to represent themselves, they have Parkinson's disease, they come with a family or caregiver, document that you're getting the history from the family because that counts in category one. Now, remember for high, you only need two out of these three categories. The second category, independent interpretation of tests, if you're looking at prior endoscopies, for example, if I see an endoscopy done by Dr. Biscaglia and I'm looking at the images to help determine my approach for an ulcer that I'm looking to do another endoscopy for, and I document my interpretation of those images, could be a CAT scan, could be an X-ray, you're going to get credit for that. Category three is discussion of management or test interpretation. If I'm now calling Dr. Biscaglia as an advanced endoscopist and discussing what he found on that endoscopic ultrasound, if I'm discussing with a radiologist or with a primary care doctor in terms of why they sent this patient to see me, document that conversation and you will get credit for it. Now let's talk about risk, which is the newest category and one that people are most unfamiliar with. The major difference between moderate and high in terms of risk is the presence of identified patient or procedure risk factors. If your patient's on Eliquis and you're holding it in anticipation of your procedure, that's high. If your patient is on an SGLT2 inhibitor and you're holding their Farsiga because of the risk of euglycemic ketoacidosis, that's high. Make sure you're getting the credit for what you deserve. Now let's talk about diagnosis or treatment significantly limited by social determinants of health. This is new. There are social determinants of health ICD-10 codes that started in 2023 and expanded into 2024. How many of you have patients who come back, keep getting admitted to the hospital because they're continuing to drink or because they can't afford their diuretics? There are now ICD-10 codes, Z91.190, non-adherence to medical treatment, financial hardship, that you can and should include in your note, in your subsequent ICD-10 codes to justify your level of billing. So document these risk factors in your assessment and plan. Get the credit you deserve. It's not because of your poor management that the patient keeps coming back to the hospital or to your office. So that was determining your level of billing by MDM or medical decision-making. Now we're going to switch gears and talk about time. I've included the E&M codes for office or outpatient visit and subsequent visits. These are the times associated with them. The important thing with time is it's based on the total time you spend on the day of the encounter. It's no longer face-to-face time. It's time you spent reviewing tests, performing the history exam, documenting, coordinating their care, following the subspecialists. Reviewing the records the night before or the week before no longer counts, unfortunately. So you have to be careful about your documentation. And really the best advice is to split it up and say, I spent 20 minutes on the day of the encounter reviewing tests and labs and old notes. I spent 30 minutes in the history and physical exam, et cetera, et cetera, if you're going to bill by time. Now these are the inpatient times. But as you can see, in order to get to a high, you've got to spend 75 minutes with that patient on that inpatient day. And mark my words, there are insurance companies who eventually will be adding up the time and there are only 24 hours in a day. So be careful. But I would say that it's really hard to do that, right? 75 minutes for an inpatient, that's tough. So I think the strategy is for the most part, get to your level of billing using medical decision making. But if you have a low medical decision making, but you've spent an enormous amount of time counseling the patient, talking them through the procedure, discussing the risks and the benefits and talking to their family and calling all different consultants, and that time adds up, then bill by time. Because then you'll be able to justify even a low MDM if you've spent that time doing the work. Again, it comes back to getting the credit for the work that you're doing. So gastroenterologists seldomly evaluate or manage complex patients, true or false? Clearly false. But as a show of hands, I'd like to ask this question. How many of you, for 60% of your billing, bill a level five? So for the record, I see maybe one hand, that's probably my fellow GI hospitalist out there. How many of you bill 60% of your visits, your consults, 60% of the time level four? Okay, so far more hands. In the 1990s, it was about 50% billing level five. And this is more recent data, thank you to Kristin Vaughn and Kathy Mueller from their consulting firm. About 5.2% of consults' office visits are level five, 50% level four, 36% level three. I'd like to help shift and move that needle. If we can make it so that 99205 is billed more than the level twos, that makes much more sense for our practice. And if you can shift from level three to level four, I'd like to see that needle move to 60%. I'll tell you what, insurance companies are also looking at billing practices. And if we don't do this, if we don't bill appropriately, we're just shooting ourselves in the foot. We all know the excuses. I don't want to get audited. If I just bill in the middle of the road for everything, I'll be fine. I make more from my procedure, so what's the point? Well, let's talk about the procedures for a second. A level four outpatient initial visit is actually worth more in terms of work RVUs than an EGD with biopsy. A level three inpatient hospital consultation is worth just as much as your colonoscopy with biopsy. So obviously none of us are going to be sitting there saying, ah, I could have had a 99214, but this is important stuff. There's money left on the table. If you just moved a visit from level four to level five or level three to level four, four visits a day, three days a week for 48 weeks a year, that's $23,000 extra. If it's a four-person practice, that's $92,000, and if it's a 20-person practice, that's enough to hire two nurse practitioners and another MA to take more care and to offer more services to your patients. So we're going to segue a little bit to split share. On the inpatient side, many of you have nurse practitioners who work with you. The rule is that the bill must be submitted by a practitioner to perform the substantive portion of the encounter. And the substantive portion is all the rules we were just talking about. It's either medical decision-making or whoever performed more than half of the total time spent taking care of the patient with no overlapping time. Attach a modifier FS when you drop the bill. But this is the important nugget that's buried in a language that a lot of people don't know or haven't paid attention to. The person who drops the bill, who performed the substantive portion of the encounter, does not need to be the person who performed the face-to-face encounter with the patient. We take advantage of this at our practice, where my colleagues are busy in the office seeing patients, but they're on call. The nurse practitioner sees the patient, discusses it on the phone with my colleague. As long as my colleague documents the entire MDM and the assessment and plan by themselves, they can bill as the person who performed the substantive portion of the encounter. And you get 100%. Remember that if your ACPs are billing, they only get 85% of the total bill. Billing for advanced endoscopy. If you do ESD, make sure that your services and your facilities are dropping HCPCS code C9779. It's worth about $3,600. It's a technical payment. It can be used by hospitals to report ESD procedures performed in the outpatient setting. That's not physician fee. So there are currently no current procedural terminology or CPT codes for ESD. But the advice is to bill an unlisted code and the unlisted codes I've listed here based on their location of the procedure. So ESD esophagus, for example, you're going to put unlisted code 43499. But in box 19, and I'll show you that in the next slide, in box 19 of the claim form, you're actually going to put in there that it's a comparable surgical code 43100, which is worth 9.66 work RVUs, or 43101, which is worth 17.01 RVUs. One's a cervical approach and one's an intrathoracic or intraabdominal approach, and that's why there's a difference. But it gives you a basis for negotiation with your insurances and your payers. ESD stomach, you're going to put 43999. And in box 19, you're going to put 43610, which is worth about 16 RVUs, and 43611, which is about 20 RVUs. And then ESD colon, the comparable surgical codes, 4110 is worth about 14, and 44111 is worth about 16 work RVUs. Note the complexity of the procedure and the amount of work involved clearly in your procedure note. Add the time that it took to do the procedure, it took 1.5 hours to perform the procedure, and then don't forget about box 19. The second piece to this is you're going to prepare a cover letter describing the benefits of the procedure when done endoscopically versus open and laparoscopic. The nature of the procedure with detailed description of the physician's work. Don't spare the details, include the time, the intensity, and the risk, and of course, any extra equipment that you use. You're going to hold on to that cover letter. If you submit that cover letter with the initial claim, it's not going to go anywhere. Any unlisted code is going to be stopped and then sent back to your office for request for more information. That's the point when you're going to submit that cover letter. So here's what box 19 looks like on a paper form. Everything's electronic now. There's box 19 there, and your billers should know this. And if they don't, hire a different biller. Cover letter is so important. These are tips and tricks to make sure that your cover letter is complete. Write that the endoscopic procedure is advantageous and preferred over open and laparoscopic surgery for this particular patient, that it improves the quality of care for the patient by allowing the patient to return to normal activity sooner, that it reduces cost as compared to an inpatient stay, and it reduces the risk of nosocomial infections or complications, and that the fee should be based upon the RVUs of a comparable surgical code that are open or laparoscopic given the amount of physician work involved. So for pancreatic necrosectomy, you're going to drop 48999. That's the unlisted code, and the comparable surgical code would be 48105, which is worth 49 RVUs. Now, you're not going to get 49 RVUs, trust me, but it's a basis for negotiation. An edge, you drop 47999, and the comparable surgical code is 43240, which is worth about 7 RVUs. Remember box 19 and your cover letter. Finally, let's talk about HCPCS code G2211. You didn't think I'd get through this slide deck in 20 minutes. I have two minutes to spare. So HCPCS code G2211, it's an evaluation and management visit add-on code. So it's an add-on code to your office initial and outpatient visits. It was really meant to boost up the payment for primary care doctors, but for subspecialists with a cognitive load, it helps to reimburse you for medical care services that are part of ongoing care related to a patient's single serious condition or complex condition. I can think of IBD, IBS, achalasia, cirrhosis, GERD. The point is it's worth 0.33 work RVUs or a total of 0.49 RVUs. That's an additional $16 per claim, but remember there's a volume multiplier. So over your span of a year with the number of patients that you see managing their complex chronic conditions, this can add significantly to your reimbursement. It's reward physicians for the cognitive load of the continued responsibility of being the focal point for the longitudinal care and the diagnosis and treatment plan of a patient. I would recommend documenting the necessity for G2211 in your assessment plan that you're the one managing those medications and those conditions. It's not to be reported if you're using modifier 25, but currently CMS has no regulations with regards to this code, so trust me, the orthopedic surgeons, the vascular surgeons are taking advantage of it. We should too. From our own experience at Peconic Bay, these are the insurers that are paying for it. You can see Medicare pays for it, Medicaid does not. Of note, Meritane Health, I hope nobody hears from Meritane Health, they're only paying for 0.01 RVs, which is like 33 cents. But for the most part, everybody else is paying for it and it's worth doing. So these are some resources. If you have any other coding questions, please email codingquestions at asge.org. You can email me. I'm happy to help if I can. But I'll close with this. Throughout his professional career, Dr. Gene and Lynn Overholt was an innovator and an entrepreneur. He dared to think differently. He never settled for the status quo, all in the service of improving patient care. My hope is that this talk honors that mission by helping you to do more and to deliver the very best care to your patients. Thank you.

Gene Overholt

gastroenterology

flexible sigmoidoscope

endoscopic therapies

billing practices

reimbursement rules