Hello, everyone, and welcome to a presentation on Medical Necessity, the Key to Economic Success, sponsored by the American Society for Gastrointestinal Endoscopy and the ASG Foundation Beyond Our Walls Campaign. My name is Michelle Akers, and I will be your moderator for today's call. The presenter for today's call is Kathy Mueller. Kathy is a healthcare consultant with over 35 years in healthcare experience, including ICU, CCU Nursing, Physician Office Administration, GI Claims Submission and Adjudication and Seminar Instruction. She is the owner of Ask Mueller Consulting, LLC, providing consulting services for physicians nationwide. Kathy is a nationally known speaker and the author of many multi-specialty medical and surgical coding workbooks. She has a great amount of experience in gastroenterology, surgical subspecialties and pediatric subspecialties. Kathy is also the co-editor of the ASGE Coding Primer and answers the coding email for ASGE. Before we get started, just a few housekeeping items. There will be a Q&A session at the close of the presentation, and questions can be submitted at any time online by using the question box on the right-hand side of your screen. If you do not see the question box, please click the white arrow and the orange box located on the right side of your screen. Please note that this webinar is being recorded and will be posted on GILeague, ASGE's learning management platform, in approximately one week. As a registrant for this webinar, you will have access to the recording. The presentation slides for today can be downloaded during the slide presentation at the right side of your screen and will also be available in GILeague. At this time, I would like to turn the webinar over to Kathy. Kathy? Okay. Thank you, Michelle. And let's go ahead and get started. So everything is current as of today, and you can know pretty well that there have been changes after the Medicare fee schedule, the position fee schedule was released on November 2nd. We have been getting updates and to the fee schedule and also some policies surrounding that as well. So guys, you know, keep your eyes out for bulletins from your Medicare payers, the Medicare fee schedules, and also as well as bulletins from all your commercial payers as well. We are right now in the prime area between October and January for updates, sometimes on a daily, but at least a monthly basis. So make sure that you have somebody who's in charge of looking at that in your practice and distributing all the updates to all of the providers, coders, billers, schedulers, pre-authorization folks as well. All right. So what we're going to talk about today is the new fee schedule for 2022. We're going to talk about obviously medical necessity and some of the topics in particular to medical necessity, such as EGDs, infusion services, hemorrhoid treatment path, MAC, as always screening versus diagnostic, and then some principles of medical record documentation as well as some endoscopy tips. So the very first thing we're going to talk about is the 2022 physician fee schedule. Like I said earlier, on November 2nd, CMS released the final rule, and if you want further information on that, there are two links here. One is a fact sheet, and that is the first bulleted item, and the second one has to deal with the full notice, full notification, which is pages and pages long. So with the budget neutrality adjustment that we had, that 3.75% temporary increase that was put into play last January, all right, that's going to expire. So we're going to end up getting a decrease of $1.30 from our current conversion factor of $34.89. So beginning January 1st, the conversion factor is $33.59 per relative value unit. Relative value units, total RVUs, are based on three components, the work RVU, so that's the provider work, the malpractice RVU, as well as the practice expense. So there's three components in the total RVUs, and that multiplied by $33.59 is what you get for the national fee schedule and the Medicare fee schedule. Now, keep in mind that a lot of your contracts are based upon a percentage of the Medicare fee schedule, all right? So that being said, that also can affect your work. Your commercial payers will pay you as well for approved amounts after January 1st. So make sure that, again, that you update your system. Good time to update the system for approved amounts is between Christmas and New Year, so you're ready to go on January 1st. So let's kind of talk about overall medical necessity. I think we all know that without medical necessity, we will not get preauthorization. And remember that medical necessity lies within your documentation or lack thereof. So most payers require preauthorization for endoscopies, any type of radiologic studies or capsule studies, infusions, et cetera. All of that require, a lot of these people require preauthorization. And so if we don't have proper medical necessity, services won't get paid. So how does that get reflected on a claim? It's not necessarily your preauthorization number, it's the diagnosis code you submit. Primarily, the first diagnosis code is what supports medical necessity. Without medical necessity, recoupment of previously paid services will be obtained by payers. So that means that something on your claim triggered a review, and oftentimes it is a post payment, not necessarily a prepayment review. So again, when you get your explanation of benefits back, if you don't get paid, we have to look at a denial reason to figure out why we weren't getting paid. And sometimes it's difficult because there can be two, three, four different denial reasons in there. All right. But again, if this is something that you've already gotten paid for, and now they're looking to see if they should have paid for it, all right, if they find out that it wasn't, medical necessity was not met, they can ask for their money back. Top medical necessity areas of payer focus are kind of pretty well what we're going to be talking about and what I went over just a little bit ago. So let's talk about diagnostic EGD. Now, Anthem, Aetna, Tufts, Humana, United, there are more payers out there that have policies for EGD. And to search for this often by payer, you don't necessarily look up for EGD policy. You're going to look under upper gastrointestinal endoscopy policy. And before 2018, most of our payers did not require preauthorization for diagnostic EGD. It was kind of not a freebie, but it was pretty well, as long as it was done as an outpatient service, it was approved. All right. Now, it's not that same way anymore. So Anthem was the first one to start it in September of 2018. And then a lot of the commercial payers followed suit. We've had a local coverage determination policy from our Medicare carriers off and on, not everybody has it. And so what they did with as far as the commercial payers reflected a lot of the indications and let's put it this way, the indications that Medicare has stated for years, and then the contraindications as well. So these are the indications, upper abdominal signs or symptoms. So gastroesophageal reflux symptoms that persist or recur following an appropriate trial therapy for two months or more. And this is so important, symptoms, symptoms, symptoms. You can't just say GERD symptoms. That doesn't mean the patient has GERD and GERD by itself is not approved. All right. So what are the symptoms that the patient has? How long have they had them and what type of treatment has been initiated that has not been successful? That all has to be documented in there. And oftentimes we see on the endoscopy report itself, it states this, GERD symptoms that persist or recur. So it's kind of this little canned text on there. And this is for more of a quality measure, GI quick measure. The thing is, we still need to know what the symptoms are because what happens if we don't find any abnormalities, right? Symptoms are very important. Vomiting is covered, unexplained dysphagia is covered, signs or symptoms suggesting structural diseases of the upper GI tract. That is also kind of a canned text as well, list the symptoms. And I try and tell all the doctors, especially when they're documenting on their endoscopy reports, list everything, list every symptom that the patient has to support biopsies, to support the need for endoscopy to start with. We need to have that information. Postoperative bariatric surgery with persistent abdominal pain, nausea or vomiting. So again, any type of bariatric procedure could be an asleep gastrectomy. It could have been a band. It could also have been a bypass situation. So, you know, have they been following dietary modifications and counseling or not just dietary, but also exercise? You know, so what's been going on with this patient? Obviously any type of bleeding is indicated. Unexplained anemia due to either blood loss or malabsorption from a mucosal process. So iron deficiency anemia is covered, chronic blood loss anemia is covered, but anemia unspecified is not. And I know we do deal with those patients. We get some patients from the primary cares with just anemia. Well, that's covered for a visit, but it's not necessarily covered for an indication for upper and lower endoscopy. Documentation of esophageal varices in individuals with suspected portal hypertension or cirrhosis. The take home on this is if you're screening a patient for varices, why? Why do you suspect they have varices? Because they have what? Liver condition, cirrhosis, portal hypertension, hepatic fibrosis, anything like that. Document why you suspect the patient has varices. To identify upper GI etiology of lower GI symptoms, such as what, diarrhea, and you're ruling out celiac disease. To evaluate persons with radiographic findings suggestive of echolasia. Not medically necessary. So this is anybody that's asymptomatic. There is no such thing as really a screening EGD with the exception of Anthem and Barrett's esophagus. So Anthem is the only payer that allows for screening for a male over the age of 50 to rule out Barrett's esophagus. The rest of the payers do not have it covered. All right. So other than that, if somebody is coming in because they need to have some type of EGD done because they're going to undergo preoperative evaluation or bariatric procedures, technically a screening EGD is not considered covered. Make sure the patient signs an ABN or some type of waiver instructing them that it's not considered a medical necessity. Signs for any of the following, healed benign disease, gastric atrophy, pernicious anemia, fundigland polyps, gastric intestinal metoplasia. We got some new diagnosis codes for those beginning October 1st. And some of our payers are in the process of adding that as an indication for EGD due to some recent updated information. All right. So I think you will see that gastric intestinal metoplasia will become covered by most of our payers after January 1st of 2022. All right. So confirming H. pylori eradication is not an indication. And I've seen that a couple of times as indications for upper genioendoscopy. So that's not usually the correct indication. Again, we're back to symptoms. Prior to bariatric or non-gastroesophageal surgery in asymptomatic individuals, obtaining tissue samples from endoscopically normal tissue should diagnose, skirt, or exclude bariatric esophagus in adults. Guys, this is not just for that. Why are you biopsying normal tissue? What symptoms do the patients have and what are your differential diagnoses? You got to have that in your notes. You have to have it. It's not just for your indications for biopsies, what the pathologist also needs that information to determine what additional stains might be required and what are you suspecting. All right. So here are some links to payer policies. And again, if you want to look for every payer that you're dealing with and not just the ones I have listed here, search under upper gastrointestinal endoscopy policy. Medical necessity on infusion services. All right. So we get a lot of questions is why are we getting paid for infusions? All right. Why are they requesting records all the time? So do you have the documentation in the record to support the reason for the initiation or the change of the biologic agent? All right. So a lot of times that information is obtained in the chart, usually lab studies, our patient signs and symptoms. We are seeing payers requesting records at both the time of pre-op and also after claim submission. So prepayment often reviews are requested on these. These are high dollar amounts, especially if you are providing the medication. All right. So again, make sure your I's are dotted, your T's are crossed. Do you have the specific IBD condition documented? So we have seen payers pending if the diagnosis of Crohn's, relapsed or colitis is just unspecified. So if you're taking care of this patient, remember the infusions or incident two services, you're treating this patient, you ordered the infusion. So you ought to know where the disease process is. All right. And that's what the payer's reasoning is too. You ought to know the specificity. Where is a specific area of focus of their IBD? All right. So next issue is why are you billing a visit on the same day of infusion? Was it medically necessary or you're just seeing how the patient is doing since the last infusion? So did you order anything? Are you adjusting medication, et cetera? It has to be something other than how are you doing in order to bill that visit on the same day. And that visit requires a modifier 25 and modifier 25 means unrelated to the service that you're providing that day or more above and beyond what you did. All right. So your documentation has got to be specific in order to support the visit on the same day of that infusion service. Multiple endoscopy procedures, and we're going to spend a little bit of time on this one. This is multiple endoscopy, SNARE and cold-pore biopsies. Since March 1st of 1993, that's when the multiple endoscopy policy became in effect. Medicare states, and you can actually find this information in the correct coding initiative policy, CCI policy. And that's all you have to do is search for that, the CCI policy. All right. And you want to go to chapter six. All right. Chapter six in CCI policy relates to anything in the GI tract. In particular, section C talks about endoscopic procedures, the do's and the don'ts for that. All right. So that is very important, guys. And if you have not downloaded that information, I highly suggest that you do. So we see that payers often deny the biopsy 45380 when billed with the SNARE rule 45385. Even though you are assigning appropriate modifiers, we're talking about the XS or the 59 modifier on the biopsy because the biopsy is bundled in the SNARE, and link the appropriate diagnosis codes to the procedures performed. So we would hope to see the finding for 45380 as well as the finding for 45385, just specific to those procedures. So sometimes what we have to do is we'll get the denial, all right? And it'll say bundled into 45385, not separately payable. So what you're going to end up having to do is send the endoscopy report in there. All right. And then also make sure that the technique for each procedure is documented. So the term random biopsies has been causing payers to disallow the biopsy code of 45380 unless the instrument is documented. And the reasoning is if you look in your CPT book, and this is not just for 45378 family, it's also for 43235, 44360, 43260 codes. The head of the endoscopy families includes brushings and washings. Brushings are brush biopsies. So brush biopsies are included in the base code of colonoscopy, and remember that your base code is always bundled into every surgical endoscopy that you do. So make sure that your providers document the specific instrument you use like cold forceps biopsies, jumbo forceps, et cetera. Now if you are looking at your endoscopy reports before submitting your claims and your codes in there, if you're not seeing specific instruments documented, hold it, go back to your physician and say, hey, we need an updated report. We need to make sure that that information is in there. Make sure that there are indications and findings for every lesion that is treated. I just mentioned that before. Why would normal tissue be biopsy? So you would have to be ruling out some type of symptom or was there redness, there were there nodules, anything like that. It could be a ridge on the anastomotic site in particular. So what are you suspecting? What are you ruling out? Okay, so pathology and special stains. So a lot of GI practices have a GI lab, all right? And some of you do the slide preparation. Some of you just do the interpretation of the slides and an outside lab does the preparation. And some of you do both, you go global. But bottom line is everything for your pathology begins with the endoscopy report. So back to the indications, back to the findings, list all symptoms to support biopsies of normal tissue. If the stomach and the duodenum are normal, why are biopsies taken? Does the patient have epigastric pain, bloating, satiety? Are you listing any differential diagnoses? So the pathology report has to indicate the patient's history if everything is normal and why were special stains added? What is suspected? The payers, in particular in Medicare, CMS is really looking at this closely and some of our commercial payers are as well. They're looking at the stains associated with upper GI specimens, all right? So we do see that there are more stains done, especially with stomach biopsies and even sometimes it's small intestinal biopsies and of course esophageal, you know, and sometimes we see loads of stains, all right, and it could be for metaplasia. It could be for bacterial infectious and it could be for any type of immunostains as well. But the bottom line is you've got to have medical necessity to support it. So we need to know why. All right, we're going to talk about monitored anesthesia care. All right, so make sure to instruct your anesthesia provider to give you both the primary risk and comorbidity issue as well as the indications of finding during the procedure. Now as far as anesthesia goes, we're talking about separate anesthesia billing. We're not talking about monitored, I'm sorry, conscious sedation, IV sedation. That's not what we're talking about. We're talking about deep sedation, propofol in particular, all right? So it is essential that we need to have the reason for MAC documented and the person responsible for that is your anesthesia provider. So make sure that they have that as far as how you capture charges. So if you have a separate anesthesia EHR program, there should be a medical necessity qualifier for anesthesia and that information should be there. So listing all of the conditions, all the comorbidities and risk factors that would support the need for MAC. All right, most of the time and the biggest issue on this is the primary diagnosis code that gets submitted with an anesthesia claim. So Medicare LCDs do have had MAC policy off and on and the only one that really has the most detailed MAC policy out there is Novitas. There's two Novitas regions out there, one's up in the upper northeast, the other's in the southwest area, all right? But they have almost 24 pages of approved ICD-10 codes to support MAC. And I would say the majority of indications have nothing to do with GI, all right? They have something to do with the patient's comorbidities and risk. So why does the patient have to have monitoring done? Because they're diabetic, because they have coronary artery disease, because they're on a whole load of psychotic medications or antidepressants, because they have taken marijuana, they use barbiturates, they're on all that other stuff. So a lot of the F codes support MAC issues. I would recommend for those of you that are not under Novitas policy, all right, that you still get on the Novitas website and download this. Now the recent policy doesn't have the list of ICD-10 codes immediately available. You have to go to the bottom of the policy and I think it's the second article that you click on that will give you the list of all of your ICD-10 codes in there to support it. This is something you want to make sure that your anesthesia providers have in their hot little hand that they look at this, all right? We have some of our commercial payers that still want the primary diagnosis as the indication. And some don't. Some want the only comorbidities and the mortality issues in particular to support the need for MAC and some want both. So how do you know? It's kind of a trial and error situation. So for those of you guys that have been dealing with anesthesia claims, I'm sure you've already created a spreadsheet by payer to know which diagnosis codes go in that primary position, all right? Make sure that you have a good way to obtain charge capture and verification of charges. So I know some of you may have an anesthesia charge ticket or sometimes you will have your EHR can print out a like a requisition in particular, but whatever that you do, make sure that your anesthesia provider knows that they have to give you not just the indication for the procedure itself, but the indication for MAC. And so audit documentation frequently to make sure that all required elements are contained in the medical record. You know, I know some practices that are listing in audit everything before it goes out. Some don't have the staff to do that and some do have an internal compliance division that does do random samplings of all of your providers, but make sure that you do look at this, document this, make sure that your providers know what they have to assign and how they have to bill and document. Screening versus diagnostic colonoscopy. This past May, actually May 18th, the United States Preventive Task Force actually finally updated the guidelines to reduce the age to 45 years to begin average risk screening. And this is a recommendation applies to, and I'm going to read it through, to asymptomatic adults 45 years and older who are at average risk of colorectal cancer and who do not have a family history of known genetic disorders that predispose them to a high lifetime risk of colorectal cancer, such as Lynch or FAP, a personal history of IBD, a previous adenomatous pilot or previous colorectal cancer. When screening results in the diagnosis of colorectal adenomas or cancer, patients are followed up with a surveillance regimen and recommendations for screening no longer apply. All right. So the US Preventive Task Force did not review or consider the evidence on the effectiveness of any particular surveillance regimen after diagnosis and removal of adenomatous polyps or colorectal cancer. So what they're basically stating is if this patient now has a personal history of cancer or polyps, and you're going to scope them more than once every 10 years, all right, that's not going to end up being a preventive benefit. That's going to be under a major medical situation. And this is one of the most common questions, agitations that we hear from our patients. All right, because of course, they think that anytime they undergo a surveillance is considered screening. Right. And they should be subject to preventive care. If the payers file the Affordable Care Act, which a lot of them do, right, then anything more than once every 10 years would be considered not covered. Right. So your hyperplastic polyps, which do not require surveillance, those would be actually average or screenings. And a lot of those patients don't come back, but for 10 years. All right. So anything other than more frequently than 10 years puts your patient at risk for non-coverage. Now Medicare, we all know, has a different policy. They don't follow the Affordable Care Act. They have their own policy. So these are some tips on screening versus diagnostic. So again, screening means no symptoms with your bowels and no findings during the colonoscopy. And I'm going to tell you, this happens a lot. We do a lot of reviews for practices and, you know, looking at the endoscopy report, sometimes we see screening and diarrhea. Well, that's not screening, especially if you're doing biopsies to a lot of microscopic colitis. All right. Sometimes we'll just see screening on there. And then we see in the body of the endoscopy report that all normal tissue, no, nothing was found, but biopsies were taken to rule out microscopic colitis. If everything's normal and the patient has no symptoms, why are you doing a biopsy? All right. And I think a lot of you listening in are going, oh, yeah, we see this a lot. Well, the problem is, and I know we'd like to give the patient that preventive benefit, but if you're doing biopsies to rule out a source of an infection, the patient has to have some type of symptom. All right. So that is considered a false claim. All right. And we got to make sure that we build these correctly, make sure our documentation reflects accuracy as well. So when a polyp or lesion is found, the colonoscopy is no longer considered screening, but a surgical endoscopy. Now, the Affordable Care Act allows for no out-of-pocket patient responsibility when average risk is the indication. And so if a lesion is found and then the facility still gets full payment and the physician still gets payment, anesthesia is still covered, and so is pathology, as long as it begins a screening. And that's the Affordable Care Act guidelines. And if you go on any of your national payer policies, they all state that. Now, remember I said that the majority of payers file the Affordable Care Act, but there are some grandfathered issues in here, which says that if for some reason the patient has a privately funded plan through a national payer who normally follows the Affordable Care Act, the privately funded plan does not have to follow the Affordable Care Act guidelines. And therefore, we may be dealing with some patients that have no screening benefits. That has gotten less and less since 2010, but it still is out there. All right, so only the Affordable Care Act guidelines allow for no out-of-pocket patient responsibility. Now, Medicare has a screening colonoscopy loophole. And actually, this basically is supposed to stop, and this was passed on December 27th of 2020. So everybody thought, oh my gosh, patient no longer has to have any responsibility under Medicare if something's found during screening. Well, not until 2030. All right, so it begins in 2023, where we see the reduction. In 2022, the patient's still responsible for the 20% that Medicare does not pay if a polyp is found during a screening colonoscopy. In 2023 to 2026, it goes down to 15%. And in 2027 to 2029, it goes down to 10%. And in 2030 and beyond, then CMS pays the full 100%. All right, so make sure that your billing staff is up to date on this. Your doctors are up to date, because a lot of them, when this came out, and I know I was in a practice last week, and they basically said, too, we thought that was taken care of in December last year. Nope, if you didn't read what the guidelines were, and Medicare finally published this and updated their information in the screening colonoscopy policy this past November, all right, to go and follow these guidelines. All right, so remember, surveillance versus screening, there's no difference for Medicare. All right, Medicare covers surveillance, and it will be covered at 100%. So they do not follow the Affordable Care Act. So for commercial payers, we recommend following the same policy as CMS, but remember that a lot of the screening issues we see are benefit-driven. So always verify eligibility, not just check for pre-authorization. There's two steps for pre-authorization. First of all, to check whether or not it requires a pre-authorization. Most of the payers will say, as long as it's done as an outpatient, no pre-authorization is required. Now, sometimes outpatient is not necessarily the key anymore. As long as it's done as a non-hospital outpatient facility, it would not require pre-authorization. UnitedHealthcare, since October 1st of this year, has a list of covered ICD-10 codes for outpatient hospital services. All right, so if you have not been on United's policy and you are a participating provider with United, you need to check that because they're basically ASA-4 medical conditions. All right, that would only allow for that service to be done in the hospital situation. Personal history of pilots may not be covered under preventive benefits by some payers, and that's kind of what we're talking about. And the utilization of Z1211 as the primary diagnosis implies average risk screening, which can trigger the payer computer to pay it incorrectly. And we are seeing payers recouping money from practices, so be careful with that primary diagnosis code. Medical necessity services on E&M services. And last year, you know, 2021, we saw the change in the E&M guidelines, and we know that the level of visits should be based upon either decision making or time. We make sure that you run benchmarking reports monthly and then yearly by provider in the entire practice and compare them to national statistics for provider specialty. If your providers are outliers, which means they bill higher or lower than the national average, then recommendation that the documentation should be sampled for accuracy and know that that is often a trigger for a payer to review records. So we are seeing payers routinely sampling 99214, 99215, so those are established patient visits level four and five in the office, and also level three follow-ups in the hospital. All right, so if they sample that, it means that you should sample these as well and look to make sure that the documentation supports it. And like I said earlier, I'm sure that some of you do sample or some of you look at everything before it goes out, but some of you may not. So there should be at least some sampling either by an internal auditing in your practice or somebody from the external. We do this a lot, but I'm sure there's somebody in your area too that you might've used before as well, something that should be looked at. So diagnosis codes can trigger a payer down code at the level of service. Actually, we've heard the Anthem, and actually it was the Indiana Anthem that was doing this, that they had submitted, and they actually had this in their computer software, that they had specific diagnosis codes that supported level four. And if that diagnosis code that you submitted on the claim or more than one diagnosis that was submitted on the claim did not meet those in their system, they automatically down-coded the claims. All right, so one of our practices had told us about that, and they had to resubmit, which means they had to send the documentation to support that they billed a level four correctly. So if one provider in the group is an outlier, so if, say, one of your doctors bills 90% of all their follow-up visits as a 99214, what do you think is going to happen? If you haven't looked at benchmarking statistics lately, it's 43% that are level four, that's the national. All right, so if anything is significantly higher than that, it can trigger a review and can trigger your practice to get sampled. So guys, how do you get this information? It's available on CMS. I mean, there are publications out there, Decision Health and some of the other national publications that also offer this too, but I do recommend that you find this information and see exactly where your practice lies. Now, the practice should still, and the providers should still pay close attention to the core elements. We know that since January 1st of last year, any of our new and established patient visit codes, the history and exam that's performed does not factor in to the level of your visit, but you still have to have a history and exam that is related to the chief complaint or pertinent to the chief complaint. All right, so the HPI, which is the history of present illness, is still so very important because it tells the story of why the patient's coming to see you and what's going on since you last seen them, and decision making tells us what are you going to do about it. All right, so oftentimes the provider doesn't fully document everything done in that encounter, and we see that more in the impression and plan, so make sure if you've got a list of three diagnoses that you're addressing, say IBS and GERD and elevated liver function studies in particular, there should be a plan for each one of these that addresses each one of these conditions. All right, and unfortunately, it's based upon the electronic medical record software that you've got on whether this is easy or a little bit difficult to do. So in particular, there's one software program that doesn't allow you to do it. In order for you to do a detailed description, you have to do a pretext in a separate paragraph underneath the impression and plan. All right, avoid using the pre-populated problem list. All right, a problem list is just that. It's a list of problems that you treated and managed on this patient, and sometimes these are 20, 30, 40 different problems depending on how long you've seen this patient, but you're not looking at every one of them every time. You want to pull from the problem list, but only list those conditions that addressed or impacted your decision making for that day. Now, if decision making does not support the level that you're assigning, then you can use time to support your billing. So we had some revision on time for the established patient visits. 20 minutes of total time is now required for 99213 as compared to 15. 30 minutes is compared to 25 for 99214, and 40 minutes is still required for 99215. Since this past year, since January 1st, we are allowed to do the total time spent in the care of that patient that day, which means the time to review your internal records and even external records, the time with the patient, and time spent in documenting and coordination of care, and your documentation could look like this. I spent 15 minutes reviewing the records, 20 minutes in the history exam, an additional 10 minutes documenting the visit and adding new orders. So that's 15 plus 10 is 25 plus 20 is 45 minutes. Can you just say, well, I just spent a total of 45 minutes in the care of this patient today? You can. Best practice is to break it down. All right, so the principles of medical record documentation. All right, so for E&M services, the nature and amount of physician work and documentation varies by time and service, all right, and the type of service and the place of service. All right, so first of all, the medical record should be what? Complete and legible. Now, with the advent of the EHR systems, most of our records in the hospital as well as in the offices are computerized and they have an EHR format, but not all of them. We still see anesthesia records handwritten. We still see infusion records handwritten, and it's okay. I mean, as long as you're hitting the points that have to be documented and as long as it's legible, it should support it, but legibility is a problem. You know, so if, you know, a lot of times when we do reviews, our records are scanned to us, all right, and it's all encrypted and it's completely safe and it's HIPAA compliant, you know, so if they're scanned, I can actually magnify, you know, increasing 100% to 200% or whatever and try and make it out, but sometimes I still can't read it, and if I can't read it, it doesn't deem to exist. All right, so make sure, you know, if you're looking at this and you're doing a review or you're looking at the records to support billing and you can't read it, your auditors won't be able to as well. All right, so maybe for a different provider, sometimes we've got some providers, the handwriting is perfect, some that's not, right, so maybe you may need to do an EHR format for those providers that are not legible. The documentation of each patient encounter should include the relevant history, the findings, any type of prior diagnostic test results, the assessment, the impression, the diagnosis, the plan of care, and the date and legible identity of the observer, right. Date and signature are very important. The signature has to be on every medical record that you are billing or is not considered a legal document, would be considered a false claim. So if not documented, the rationale for ordering diagnostic and or other ancillary services should be easily inferred. All right, you know, sometimes it's like if it wasn't documented, it wasn't done, but sometimes if the list of the patient's symptoms and are in there, the differential diagnoses may not need to be needed, but it might not be the case. All right, we do see problems with CTs and MRIs. We see problems getting them approved. We see problems with EGD services not getting approved timely. So a lot of times this is based upon the documentation in the medical record or the lack of sufficient documentation in the medical record. There are some times when we do reviews, I can't figure out why the patient was even seen that day. All right, so it is up to the provider to put down the reason for the visit and what you are going to do about it, not just continue this, continue previous plan of care. I have no clue what that is. Every note has to stand on its own, right. Appropriate health risk factors should be identified. The patient's progress response to changes in treatments, revision of diagnoses should be documented. And again, the CPT and ICD-10 codes reported on the health insurance claim should be supported by the documentation in the medical record. Now, I do know that when we look at a lot of visits that not every office visit often gets reviewed, right. Sometimes it doesn't even get sampled appropriately, but again, some of you listening may say, well, we look at everything. All right, again, if your system is not set up that every office visit note gets looked at beforehand, I guarantee you that your docs and your providers are not utilizing correct diagnosis codes on these claims. They're not specific and they're often wrong because they can't find them or they don't document to trigger the correct ICD-10 code to be added on the claim. Doing a search in some of your EHR systems for specific diagnosis codes is difficult. And oftentimes we hear from a lot of providers, I don't use our software system, I use Google. And it's true, it's easier and quicker to find some diagnosis codes in Google than it is to look it up in your system. Assessment of the patient should be clear and include any details in the diagnoses. Do not code from a problem list, I pretty well told you about that. When comorbidities and risk factors play a role in the provider's medical decision-making, they should state them and why. This is missing in the majority of visit notes we see. You know, in order to bill a level four new patient visit with a new requirements, our new E&M guidelines, the patient's undergoing endoscopy has to have risk factors, whether or not they are, the level of risk is supported by this. So we're talking about respiratory, it could be cardiac, it could be renal issues. It also could be specific previous surgical history that makes the procedure risky or the specific procedure being done is advanced, but it should be detailed and your provider should be documenting that. The plan of care should show E&M, our treatment of each condition that relates to an ICD-10 code on the claim. So we also know this, that conditions may be addressed and treated, but often don't make it into this assessment and plan. So again, make sure that a lot of times there's information in the HPI that does not get put into the impression and plan and where your ICD-10 codes come from to be added to the claim is from your assessment and plan. So these are some, and I'm not going to read through each one of these, but this is information on each one of our Medicare patients, payers on cloning, all right, which means that you did a cut and paste, whether you do it in the office or the hospital. So Noridian, I'm just going to read you what Noridian considers to be a clone. Note, if only the data service and vital signs are different, then Noridian would most likely consider it cloned. We do realize that there may not be changes day-to-day that detail the stability of the patient, but it is important to include the details in documentation. To repeat a family and social history on visits every week or two would be considered cloning, or at least not reasonable and necessary. And you know what, we look at some of the inpatient notes. Oh my gosh, they're 23 pages long, contains information that's really not pertinent to what you did today. Your providers can actually create templates in the hospital to know what they want to pull in from a previous day's note. You know, so again, pre-population of medical records is not, let's put it this way, is risky as well. So NGS has information, CGS has different information, Palmetto, WPS, you know, so we've got a little information from all the, all the payers in there, you know, and you can, they all have their information that they're looking at this more closely. And we're seeing this more specifically on subsequent inpatient visits. We're seeing them request two or three days worth of notes because they're looking for that. So here are some billing tips. Endoscopy billing tips. You can't bill for multiple polyps and lesions removed by the same techniques. So if you did 12 polyps removed by SNARE, we can only bill for one of these. Now, what happens if it took you an additional 10 minutes to do? Not going to get you any additional money. So remember, modifier 22 is for an unusual procedure, only if your documentation supports tremendous complexity and the overall time spent to complete this procedure. Remember that each one of our procedure codes within the Physician Fee Schedule has a time component that is built in to the total RV years for the pre, the during, and the post procedure. And that's also published every year. It's available for 2022 as well in the CMS Fee Schedule. You can bill for each technique utilized to treat different lesions. We talked about that earlier, making sure that the location, the size, and methods used to treat lesions are documented. EGD with biopsy is bundled into any esophageal dilation code, and that's been since 2018. So the only time that we can bill for that biopsy, if it is outside of the dilation zone. So if balloon dilation was done, since it just encompasses a very small area, we could bill for a biopsy outside of that dilation zone in the esophagus. But if a savoury, the guidewire dilation is done, that usually encompasses the majority of the esophagus. So we could only bill for biopsies in the stomach, actually should be small intestine, not esophagus. Biopsy is also bundled into several ERCP codes, such as sphincterotomy and stentilation and dilation. So again, if you're biopsying the area that you're addressing with these other techniques, you cannot bill for that separately. Double balloon enteroscopy has no specific code for the anal approach. For the oral approach, you're going to use the enteroscopy codes, whether or not the ileum was visualized. For the anal approach, if a colonoscopy was truly done, along with the retrograde balloon enteroscopy, past just the terminal ileum, we can bill 45378 and 44799. An EMR should be used when billing for an EMR with a description of the procedure. You've got to utilize the term endoscopic mucosal resection. This is often pended by payers to make sure that the documentation supports the description of the EMR. I talked about this earlier. Make sure that your indications are clear. Do not use the term upper GI symptoms. Be specific as to the type. Incidental and dilation, dragging of the balloon is considered part of an ERCP done to remove stones. So if there truly is a dilation done separate with a balloon dilator, make sure that your physician documents the location of the structured or the narrowed area in order that we can utilize a 59 or XS modifier that this was not part of the incidental dilation. So important. The note has to be dated and signed or it is considered a false claim. Make sure to document the location of each stent placed during ERCP to allow for accurate claim submission. All right. We can bill for each stent separately during ERCP. We cannot bill for more than one stent outside of ERCP. All right. So if you put two stents in the small intestine, we can only bill that once. But if you're putting in two stents during ERCP, we can bill for each stent. Usually two automatically gets paid. Anything more than two would have to be reviewed. Chalangioscopy, our spyglass, document that in, let's put it this way, chalangiography is not separately billable. That's part of every ERCP. That's an injection. The chalangioscopy, which is a scope within a scope, does have an add-on code, 43273. Make sure that you put that information in your endoscopy report. And along with this, the next one is a sidebar with that. If you're doing your own interpretation of biliary and or pancreatic duct images during ERCP, remember that you can bill for this as long as there's documentation to indicate that your endoscopy provider personally interpreted the images. There has to also be kept a static image on file and make sure that the radiologist is not also billing for this as well. All right. So it is billable as long as there's documentation within the medical record by your doctor that says they did personally interpreted the images. All right. And that nobody else is going to bill for it as well. When banding or treating hemorrhoids, endoscopy is included in the procedure and it's not separately billable. All right. Control of bleeding is bundled into every single procedure that you do, unless you're addressing a separate site or lesion like an ABM or an ulcer that's actively bleeding. And the modifier 59RX always gets added to the control of bleeding code. So doctors need to specify location and why they're doing this. If you're doing any unlisted procedures, all right, which we actually bill as a 9-9 code by anatomic site. All right. We know we have to create a fee to support it. And the development of the fee should be based upon our views of procedures, even if they're open or laparoscopic. All right. And so there's rules for this that we have to follow. And any unlisted code does cause a delay in payment and it's going to be reviewed. All right. You're going to have to submit the note for payment. All right. So just our little pearls of wisdom on here. Always list symptoms. All right. And also remember your preauthorization step. I rely on the specificity of your documentation. And any delay in preauthorization directly impacts patient care. Make sure that all pertinent comorbidities and risk factors are listed in the assessment impression and plan. Make sure that specific indications are listed in your endoscopy procedures. Any lack of specificity and vagueness directly impacts your reimbursement. All right. We're talking about delayed payments. And again, back to possible recoupments. Make sure this is probably number one. Make sure that all documentation is completed and signed in a timely fashion. Come on. You know, your memory after three, four, five, six, 10, 12, 15, 30 days is not as good as it was immediately after the procedure that you did. All right. Or the visit notes in particular. Make sure and get them done. Keep up to date on all payer policies. Make sure that all providers, preauthorization billing and coding staff are aware of any changes. All right. And last but not least, if it isn't documented, it wasn't done. Thanks, Kathy. And again, we thank you all for joining us today for this ASGE webinar on Medical Necessity and Economic Success. At this time, Kathy will address some questions received from the audience. As a reminder, you can submit a question throughout the question box. If you do not see the question box, please click the white arrow in the orange box located on the right side of your screen. It's towards the bottom. So, our first question, Kathy, is, can you please let me know how you would code an ERCP with sphincterotomy, but with unsuccessful cannulation? Is this 43235 or 4326252? In quotations, despite multiple attempts and positioning, cannulation was not able to be obtained to neither the CVD nor the pancreatic duct. Okay. That's a good question. You did a sphincterotomy. So, you're able to bill the 43262. But since you couldn't complete it, I would add the 52 modifier to that. So, it would be 43262 with a 52. Now, anytime you add a 52 modifier, it will be reviewed to determine payment. All right. So, you know, if you submit with a 52 and you say, well, they didn't pay it, they're not going to. So, modifier 53 or 52 never gets you paid immediately. It's always on a review situation. Thanks, Kathy. Our next question is, we've had Anthem and Humana office visit claims denied with valid abdominal pain diagnoses. Do you have any insight on this? Is it basically because you used, I guess this needs to, I'm going to ask the question back. If you're utilizing R10.9, which is abdominal pain unspecified, we are seeing some of those claims come back simply because of the lack of specificity associated with it. Again, a lot of times the specificity is in the HPI. But if it's not brought down into the impression and plan, then sometimes it just comes as abdominal pain. You know what? A lot of providers will tell you, I can't find generalized abdominal pain. And they could be able to find it. It might be how it's worded in your system. And it doesn't trigger that. A lot of times it's generalized abdominal pain that they actually they're searching for, but they just don't put it in correctly in the impression and plan. So, I would think that if you're looking at the denial reason on your EOB, it most likely will be say it lacks specificity. And if that's the case, that's your problem. Thanks. Our next question is, why is 43239 being denied when billed with a SAVRI dilation 43248? Okay. It's kind of like what I just talked about. It depends upon what diagnosis code you're utilizing for 43239. And remember that you can only bill that if it's outside of the biopsies outside of the esophagus. So, if it is outside of the esophagus, you do need the 59 or the excess modifier. I'm going to recommend you use excess over modifier 59. Most of our payers, but the exception of Medicaid and some of our regional payers may not like the X modifiers, but most of the other payers do. And it doesn't seem that there's that computer edit that automatically denies a claim with the excess modifier as it does with modifier 59. But that's probably it. I would look at your diagnosis code. And if you're, you know, sometimes your docs are biopsying the esophagus, the stomach and the small intestine. I would recommend putting the stomach diagnosis or the small intestine diagnosis in the first position. All right. Just to make sure that, you know, you're telling the payer this was separate, this was outside the esophageal structured area or the esophageal area that we dilated. Thanks. Our next question is, when billing a screening colonoscopy, does the pathology require the screening diagnosis as well? Okay. It probably should. Because like I said before, most of the payers that follow the Affordable Care Act policy state that as long as it started as screening, that all out of, there would be no out-of-pocket to the patient. But the problem with this is modifier 33, which is for screening, or modifier PT, which we use for Medicare, which means it started as screening and converted to diagnostic, isn't allowed on PATH claims. So the only way that the pathology claim can trigger screening is if you use it in the first position. But we do know some payers won't allow screening in the first position for pathology. So the best thing you can do for this is to utilize your comment field, which is field 19 or box 19. And in there you would just document began as a screening colonoscopy indication with screening, something like that, so the payer knows that. All of your claims have the ability to transmit, or all of your claims have the ability to transmit comments. There is usually no restriction on the amount of comments electronically. It's just that our software vendors restrict them to say 45 characters. So it's like keep it simple, you know, so indication with screening, colon screening. And so the payer would know. Thanks. Our next question is, why is it taking up to two weeks to get pre-authorization approval for an EGD? All right, I kind of went when we were talking about that before. It has to deal with the lack of documentation for medical necessity, you know. So remember that a lot of payers are looking at EGDs and the indications. And if your providers don't document exactly what the patient's symptoms are, what the treatment is, has been done, what was the patient's response to that, and what they're ruling out, that's what's causing a lot of the denials and delay in pre-authorization services, you know. So again, back to the provider's documentation is essential to guaranteeing timely care for the patient. Thanks, Kathy. I think this will be our last question because I don't see any more in the queue. So our last question is, why are payers delaying payment on infusions? We are often two to three months out on infusion services, which amounts to thousands of dollars. Okay, so kind of what I was talking about before is that a lot of them are doing pre-procedure reviews and pre-infusion reviews, even for pre-authorization purposes. And then when you submit your charges in, then they come back and ask for the documentation, you know. So they are making sure that the documentation supports accuracy, the specific location of the disease process, the units given. And also, you know, you're looking at approved maxes in far as the maximum amount of dosage that's allowed by certain payers. They have limits on that. Most of that you can find on their websites in particular. You know, this is kind of the issue, but I think the most common denominator on this is the lack of specificity in the IBD codes. You know, where is the location of disease, right? And if that's not documented on the claim, so if you're using K50.90 or K51.90, which means Crohn's or ulcerative colitis unspecified without complications, you know, sometimes what they're doing is they're asking for records to determine. And is there a valid order? That's another thing that we find. Is there a valid order? So oftentimes the infusion record does state the order, which says five milligrams per kilogram in particular, but some of them don't. So if your payer is requesting a review of infusion services and they're asking for a sample of five or 10, if you're pulling information for that payer to support medical necessity for that, you want to make sure that you're giving them everything to support medical necessity for that service. So you're looking at the infusion record itself. You're looking for a valid order if it's not on the infusion record. All right. So there's certain things that have to be, that's what they're looking at to support medical necessity. Thanks, Kathy. And thank you all for joining us today. We certainly hope this information is useful to you and your practice. If you have any questions regarding today's webinar, please contact me listed on the slide. ASG has designated this webinar for a maximum of 1.0 AMA PRA category one credits. And as stated earlier, the recording of this webinar will be available in approximately one week on ASGE's GI LEAP for access to you. When visiting GI LEAP, you will complete an evaluation of the webinar, and then you can claim your credit. Your input will help us improving on future webinars. This concludes our webinar. Stay tuned for more future educational opportunities from ASGE. Thanks and have a safe and great day. Thank you, everybody.

Medical Necessity

Economic Success

Kathy Mueller

Fee Schedule 2022

EGDs

Infusion Services

Medical Record Documentation

Billing and Coding

Endoscopy Procedures

Thorough Documentation