Hello, everyone, and welcome to a presentation on Top Coding Issues Impacting GI Practices in 2021, sponsored by the American Society for Gastrointestinal Endoscopy and the ASGE 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 Kristen Vaughn. Kristen is a national consultant with over 16 years of coding and billing experience. This includes gastroenterology, pulmonary, critical care, immunology, rheumatology, hematology, and hospital specialties, plus seminar instruction, auditing, and on-site consulting. Her background includes extensive experience in a teaching university. She's currently a full-time consultant trainer with Ask Mueller Consulting. Her presentations have included organizations such as AGA and ASGE. She is the co-author of several workbooks and programs specific to gastroenterology. She is a certified professional medical auditor and certified ICD-10 trainer, and Kristen also answers coding email for ASGE. Before we get started, just a few housekeeping items. There will be a question and answer session at the close of the presentation. 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 in the orange box located on the right side of your screen. Please note that this webinar is being recorded and will be posted on GILeap, ASGE's learning management platform, in approximately one week. As a registrant for this webinar, you will have access to the recording. The slides for this presentation will also be in GILeap and are available for downloading in the handout section on the right side of your screen. At this time, I would like to return the webinar over to Kristen. Kristen? All right. Thank you, Michelle, and welcome, everyone, to the top issues for GI practices in 2021. We do have several topics and items that we're going to discuss today. First thing we're going to talk about is a little bit about ICD-10 updates and what we call exclusion ICD-10 codes. Then we're going to talk a little bit about the OIG Physician Task Force, so some of the items that they are focusing on for the record reviews and such. Upper endoscopy issues, medical necessity. We're obviously going to cover the review of the 2021 E&M changes. I think that's probably the biggest change or topic for the year. Time documentation in 2021. We're going to look at some clinical examples with decision-making, and we are going to end it with E&M tips, so your visit tips, documentation tips, and then screening versus diagnostic colonoscopy. All right. For the 2021 ICD-10 update, we actually did get quite a bit of new diagnosis codes. Now, you guys might be looking at this slide thinking, well, they're not really new, and they're not. They've been out since October 1st of last year, but we do want to cover them just because they still may be fairly new for the providers to get used to selecting. The first diagnosis is the esophagitis. We had other specified, unspecified, and reflux esophagitis as diagnosis codes to choose from prior to October 1st. Now, we have diagnosis codes that are related to whether the esophagitis is bleeding or not bleeding. Again, if the provider, let's say they scope the patient, and the patient does have some significant reflux esophagitis, and there's some bleeding there, or recent bleeding, et cetera, and the provider documents that, then the diagnosis we're going to select is that K21.01. Again, these are just broken down into with or without bleeding now. The next diagnosis code, we may not use this very often. This might be more for surgery or surgeons. Acute colonic pseudoobstruction, which is K59.81. We did get a diagnosis for other functional intestinal disorders, K59.89. Liver fibrosis. If you are a gastroenterologist or a practice that is seeing a patient for a liver condition, such as liver fibrosis, we have new diagnosis either unspecified, so if the provider just the patient has fibrosis, then you're going to use diagnosis K74.00. K74.01 is early, stage F1 or F2. And then advanced fibrosis is stage F3, which is the other diagnosis of K74.02. All right. Abnormal elevated transaminase. There's two new diagnosis for abnormal or elevated transaminase. And this is R, R74.01 and R74.02. Now, we always try, we always recommend that when your providers are documenting and they're seeing patients for elevated or an abnormal liver enzyme, okay, so they come to you, they're referred to your practice for an abnormality in their lab, and I'm talking about blood work. All right. That, again, causes that elevation of the liver enzymes. The providers need to be specific as to which are elevated. Okay. So is it the transaminase elevated? Is it the LDH? Et cetera, because we have different diagnosis codes for these. We did get emergency ICD-10 codes last year. These were effective April 1st of last year. Vaping-related disorder is a U07.0. And then, of course, COVID-19 is U07.1. We also have some Z codes, so diagnosis for observation for suspected either ingested, inhaled, or inserted foreign body that has been ruled out. So the patient may have, for example, you know, the patient may come in with dysphagia. We may scope them. We don't find the foreign body. So observation for suspected ingested, foreign body ruled out would be appropriate. Encounter for screening for COVID-19 is Z11.52. So this would typically be used if the patient is just coming in to be screened for COVID. All right. So you might have a patient that you might scope in your ASC at a later date, and you're going to ask them to come in to the office to get a COVID test. And they may not necessarily have symptoms. They may not have been exposed, et cetera. It's just we're going to do this screening for COVID. Now, we do have another Z code, Z20.822. This is contact with and suspected exposure to COVID-19. So again, back to either we're testing for it or the patient just, you know, you might be seeing them in the office and they just tell you that, yes, I've been around, you know, someone with COVID. Then if the patient has had COVID, it's resolved. It's, you know, no longer being treated. This would be a personal history of COVID, which is Z86.16. All right. We're going to talk a little bit about what we call excludes one guidelines. And this is we're still talking about ICD-10. And the reason why I wanted to bring this up today is because we are seeing a lot of payers that are, and this was effective kind of when the new diagnosis codes came into play, is payers are starting to enforce excludes one notes. And what this means is, and this is the unfortunate side of diagnosis codes and ICD-10. All right. ICD-10 was put out by the World Health Organization. All right. And what happened was in the United States, we utilize ICD-10 codes for billing purposes as well, not just, you know, health statistics, et cetera. So when the providers are choosing diagnosis codes, whether they're choosing the diagnosis codes in the office setting, or they have a system in place in the hospital where they're submitting charges through and selecting diagnoses through, they don't have little prompts that say, oh, these diagnosis codes can't be coded together. But if you were to look at an actual ICD-10 book that has every single diagnosis code listed, in the back of that book shows guidelines, parenthetical advice, et cetera. And so there are certain diagnosis codes that cannot be reported together. So if there's a situation where you submit a claim to the payer and you use two diagnosis codes that are excluded from one another, you're going to get a denial back from the payer that may say, you know, the diagnosis codes are not covered, they're not reported together, except when the two conditions are unrelated. So we're going to go through some of the most common GI ones. R19.5. Okay. So R19.5 is other fecal abnormalities. We usually will use this diagnosis code when we're dealing with patients that have positive stool fur occult, so that there's been blood seen on a stool test. It's a test. All right. It is excluded from the actual symptom of melanoma. All right. So the symptom of melanoma, the patient actually has blood in their stool. They see blood in their stool. So you cannot code those both together. This is a big one. And we've, I think we're used to this now, but there's still some practices that may not be aware of it. And it has to deal with colon polyps. All right. So most of the time this impacts our colonoscopies done when we find polyps. We do polypectomies. So hopefully you're waiting on pathology results, okay, to look to see is this a benign neoplasm or is this a hyperplastic type of a polyp? So if it's a hyperplastic, you're going to use the K code. If it's a neoplasm, you're going to use the site-specific D12 codes. You can't report them together. Another exclusion is when you document functional dyspepsia. You cannot code that with heartburn or dyspepsia not otherwise specified. They are excluded from one another. More exclusions. Change in bowel habits is excluded from constipation or functional diarrhea. You cannot code those with change in bowels. Hemorrhage of the anus and rectum. So this is your rectal bleeding diagnosis, K62.5. That is excluded from both K92.2 for GI bleed, unspecified, or melano, K92.1, or blood in the stool. This is a big one, GI hemorrhage. So the K92.2 diagnosis. All right. It is excluded from a lot. It is excluded from your any. Basically, it's excluded. K92.2 is excluded from any GI diagnosis that has with bleeding in the code category. So as you can see, there are a lot of diagnosis that is excluded. So acute hemorrhagic gastritis, hemorrhage of the anus and rectum, angio dysplasia of the stomach with hemorrhage, diverticular disease with hemorrhage, gastritis and duodenitis with hemorrhage, peptic ulcer with hemorrhage. So what you would do in these scenarios, let's take angio dysplasia. Let's do AVM of the stomach with hemorrhage, K31.811. You would not also put K92.2 on the claim because, again, the code description includes the term hemorrhage. So be aware. Be aware. Look at your denials that are coming through in your practices. See if you notice that you're getting more and more ICD-10 denials. You might want to make sure and take a quick look. Look at your claims and see were these excluded diagnosis together. There are also other. That was not an exclusive list. That was just the more common diagnosis that can't be reported together. So you always want to reference your ICD-10 book in your GI chapter to get all the exclusions or to make sure that you have, that your providers are aware of those codes that cannot be put through together. If you've got a larger practice, you've got a larger practice, you've got multiple providers going to different hospitals, you're relying on different medical record systems to input this information. What I would do is see if you can, in your practice management system, see if there is an edit that you can put in place that can stop that claim before it goes out to the payer and then someone either in the coding or billing department can review those and again, change, update the diagnosis as appropriate. All right. Physician task list. This is the OIG physician task list. So what is the Office of Inspector General? That's what OIG stands for. What are some of the larger risk areas for practices? The first one's billing for services not rendered or not provided as claimed. All right. So you might be thinking, well, we don't do that. You know, we definitely don't want to ever send in a bill to a payer or to a patient when the service is not documented and signed in the chart yet. That is considered a false claim. So an example, provider bills a patient's insurance company for a capsule study. No order exists and no report is in the patient's record. So sometimes we have this where, you know, think about this. If you perform capsule endoscopies in your office and you own both the technical and the professional components of the study, what happens if the patient actually swallows the capsule and we go ahead and send the bill for the whole entire service but we have yet to produce an interpretation? That's considered a false claim. So making sure that anything that you bill for, you have the documents contained in your medical record and that they are signed. Another issue, submitting claims for equipment, medical supplies, and services that are not reasonably and necessary. So this is a big one that we talk about is a provider sees the patient in the office for subsequent hemorrhoid banding. The provider can report the banding but without a change in the plan of care of an unrelated problem, the provider is not eligible to report a separate visit on that encounter. All right, so think about this. If you have a patient, let's say you do hemorrhoid bandings in the office and you have a patient on the schedule so they are already scheduled for their banding procedure and you bill that banding out with a visit, there better be documentation in the medical record that supports a separate visit and something completely unrelated to the hemorrhoid banding was addressed. So you're going to have a completely separate diagnosis for that visit. Otherwise, it's bundled. You cannot bill a visit separate. And this, I'm going to tell you guys, this is not just an OIG issue. A lot of the commercial payers are looking at this. So it's kind of like that modifier 25 issue. Modifier 25 means I performed a significant separate visit on the same day as a procedure or other service, so it better be significant, significantly separate. Another area, knowing misuse of provider identification numbers, which results in improper billing. Okay, this is another big one. We get questions about this quite often. A new provider is still not credentialed. The practice administrator works around the delay in credentialing by billing services under the ID number of another provider in the practice. This is a no-no. You cannot do this. It is considered a false claim since providers may not submit claims without their own identification numbers. So here's the thing, guys. If you have a delayed credentialing process in your practice, you better make sure that as soon as you get a hire date for that physician, practitioner, PA, CRNA, whoever it is, as soon as you get a hire date, you start the credentialing process. So those of you listening in, if you have ever worked in the credentialing department or you work closely with the credentialing staff or you might be the one that does everything, you do the credentialing, all right? If you are the one or you know, you know this is time-consuming and you are at the payer's mercy for getting that NPI number, but until you have that, you cannot bill anything under someone else's number for that new provider. Some more OIG issues. Unbundling services. So billing for services that are bundled. This happens when coders are unaware of what a procedure includes. When in doubt, coders should refer to the National Correct Coding Initiative edit list, which lists all inclusive codes. NCCI edits are updated quarterly and are used to process claims and determine appropriate payments for providers. All right? So if you're looking at your NCCI edits or your NCCI list, and if you've got a procedure in column A and another one in column B, the only way you can bill column B with a modifier is if they are done to separate lesions. So a different technique to a different lesion or different area. All right? Some of our edits, though, that are in place are set up to be, there's a hard stop. Basically meaning there are no modifiers that can bypass the edit. OK, so be aware of the edits that are in place that no matter what you do, you cannot, they just consider it bundled. So for example, all right, let's take a colonoscopy with biopsy. Well, let's say we accidentally billed the colonoscopy with biopsy and the base colonoscopy 45378. Well, those are hard bundled together, what I call them, is there is no modifier that's going to bypass it because the base colonoscopy is always included in the surgical colonoscopy. You can never bill those together. So be aware of your CCI edits. Failure to properly use coding modifiers. So when we're talking about modifier 59, OK, so modifier 59 or even the X modifiers, they should not be assigned unless they're truly separate areas, lesions, etc. So it says procedures that are not bundled should not have modifier 59 assigned. Some of the procedures we do, OK, they don't. So ERCPs are a really good example of this. So if you do a stent placement and a stone extraction, those two ERCPs are not bundled from one another. So you're not going to put a modifier on that second one just to, you know, let the payer know that it's, you know, that it was a different, for a different reason. It was a different service. ERCPs do not require modifiers unless the two ERCP codes are truly bundled. Those two that I gave you are not bundled. So to put a 59 on that second one, it may not affect your payment, but it could be considered a coding error and is included in the overall practice error rate potentially resulting in penalties. All right, so again, you may not have a hard stop error on it, but upon review, it could be considered a coding error. Another OIG issue is clustering. Example, the provider consistently bills all patients at level three. As a result, the provider overcharges some patients and undercharges others. This is a compliance risk to practices and can also cost them money by undercharging patients who could have been billed at a higher level. This one is a big issue. So we do reviews for practices all the time. We do audits. And majority of the time, when I do a review for a larger GI practice, there's one or two doctors or nurse practitioners or PAs, whatever, there's one or two of them in the practice that they'll bill nothing higher than a level three. They're like, nope, you can't make me. I'm not going to jail. So they have that scare. Like it's, if I bill anything higher than a three, someone's going to come after me. No, that's not the case. But to bill everything a level three, you are not in your bell curve for GI practices. So you would be considered outside of the bell curve to your peers or to other practices. So you may get a letter from the payer or OIG. The racks might start pulling your notes. Bottom line is the provider is responsible for knowing the E&M documentation guidelines. And they should be selecting those levels based upon their documentation of that patient encounter. That's it. It's their responsibility. Another issue, upcoding the level of service provided. So a provider consistently bills all liver patients at a level five. So it's kind of the opposite of what I just said. As the only provider in the region who sees patients with liver disease, the provider bills these level fives. The documentation though does not support a level five for the majority of these patients. This is a compliance risk and can also flag an audit because the provider could be an outlier due to the number of level fives billed compared to those billed by peers in this specialty and location. Okay. So typically, if you look at a larger GI group and you have one or two providers in the practice that do specialize in either those liver patients or those IBD patients, they tend to bill higher levels of services than the others. But to consistently bill a level five every single time, again, you're gonna be considered an outlier. Another area, and this one, you know, I was waiting for this because, you know, during the public health emergency and the COVID-19 pandemic, you know, we had all these new changes with telehealth services and virtual visits and whatnot. And Medicare, the recovery audit contractors announced that they weren't gonna be looking at claims right now for telehealth. They're like, no, we're in a pandemic. We're not gonna review claims with this information. Okay. Well, now that, you know, I don't know that we're even nearing the end of the pandemic. I personally think that it's gonna go on a little longer, but we are getting to, it's almost like the new norm. And so some of these restrictions have been kind of relaxed a little bit. So now, guess what? We're going to have audits focusing on telehealth. So phase one audits will focus on making an early assessment of whether services such as evaluation and management, opioid use disorder, end-stage renal disease, and psychotherapy meet Medicare requirements. The phase two audits will include additional audits of Medicare Part B telehealth services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology and annual wellness visits to determine if the requirements are met. Okay, so they're pretty well letting you know, alerting you that we, yes, we will start looking at these types of services. They're also gonna look at lab services during the COVID-19 pandemic. So it says preliminary analysis has shown that the number of non-COVID-19 test bill for Medicare Part B beneficiaries during the pandemic has decreased compared with the six-month period before the pandemic. Many independent labs have encountered challenges in providing COVID-19 testing. We will conduct a series of audits on Medicare Part B lab services during the pandemic that will initially focus on the effect of the pandemic on non-COVID-19 testing. The series of audits will focus on billing of COVID-19 testing during the pandemic. They're also going to look at appropriate assignment of diagnosis codes related to COVID-19. If you wanna see the full OIG list for work plan, we have that link available on the bottom of the slide. Upper GI endoscopy issues. All right, so for upper GI endoscopies, particularly your EGDs, diagnostic. These are no longer automatic approval if these are done as outpatient, okay? So this kind of started a little bit back in September of 2018. And Anthem, Anthem Blue Cross Blue Shield was the first commercial payer to issue an upper GI policy regarding mandatory pre-authorization, okay? So these are kind of similar to any, so if you are under a Medicare contractor that has an LCD in place for upper endoscopy, lower LCD is local coverage determination. So basically what it is, it's a list of diagnosis codes and indications that will be covered for upper endoscopies. They also have a list of non-covered indications. The pre-authorization requirements has caused delays in scheduling and cancellation of those procedures already scheduled. So again, if you deal with, and this is not just Anthem, these are other commercial payers as well. If you're dealing with a payer that requires pre-authorization for upper endoscopy, you've gotta be aware, the providers have to be aware of what is considered not covered or you're going to be doing the procedure for free. So I'm gonna take you through the next few slides that are diagnosing, this is again referencing Anthem policy, that there's going to be indications for covered, indications for upper endoscopy and non-covered scenarios. So again, make sure that all providers, pre-authorization staff, coders, billers, patients are familiar with these policies. Not just you, not just the administrator, not just the coder, not just the auditor or the biller. It does us no good to keep these policies sitting on our desk and not communicating it back to all staff, providers, et cetera. The providers have to know what is not considered medically necessary so they quit ordering the procedures for those indications. All right, so this is a sample from Anthem. Upper abdominal signs or symptoms, reflux that persists or recur following appropriate trial of two months or more. So in a scenario where your provider is just ordering upper endoscopy for GERD and you're trying to get that authorized, I guarantee you the payer is gonna ask more questions. They're gonna say reflux itself is not covered. We have to know that the patient's having breakthrough symptoms or their PPI is no longer responsive, et cetera. We have to get more information on that endoscopy. Persistent vomiting of unknown cause, new onset dyspepsia in patients 50 years or older, unexplained dysphagia or autanophagia, signs or symptoms suggesting structural disease of the upper GI tract, such as anorexia, weight loss, early satiety, or persistent nausea, postoperative bariatric surgery with persistent abdominal pain, nausea, or vomiting despite counseling and behavior modifications related to diet adherence or recent or active GI bleed, unexplained anemia due to either blood loss or malabsorption from a mucosal process for confirmation and specific histologic diagnosis of radiological demonstrated lesions, documentation of varices, esophageal varices in individuals with suspected portal hypertension or cirrhosis to evaluate persons with radiographic findings suggesting akalasia. So those are all covered indications. Covered indications for surveillance purposes and this all has to deal with Barrett's esophagus, okay? If you have Barrett's without dysplasia, endoscopic surveillance is three to five years. If you have confirmed low-grade dysplasia, then without life-limiting comorbidity, endoscopic surveillance should be performed six to 12 months, although endoscopic therapy is preferred, so such as the ablation procedure. If the patient has a confirmed high-grade dysplasia and life-limiting comorbidities that preclude endoscopic eradication therapy, endoscopic surveillance could be done every three months. That's really the only surveillance sort of upper endoscopy that payers really look at or approve is if that patient has Barrett's. All right, let's look at not medically necessary. Screening of any of the following, there's no such thing as screening, asymptomatic, average risk individual. So when I'm looking through endoscopy reports and alls I see under the indication screening for varices and that's it, no mention of cirrhosis, no mention of symptoms, that is not gonna be covered by the payer. There is no such thing as screening for varices. The patient either should have an underlying liver condition or they have symptoms. Follow-up screening for Barrett's after a prior EGD was negative for Barrett's. Okay, so why are you doing another one? Well, does the patient have symptoms, et cetera. Aerodigestive cancer, surveillance of any of the following, healed benign disease, gastric atrophy, pernicious anemia, fundate gland or hyperplastic polyps, gastric intestinal metaplasia, previous gastric operations for benign disease or akalasia. If imaging comes back and there's an uncomplicated hiatal hernia, uncomplicated ulcer that's responded to therapy, deformed duodenal bulb when symptoms are absent, confirming H. pylori eradication. This is a big one, the next one. Prior to bariatric or non-gastroesophageal surgery in asymptomatic patients. So sometimes I see practices that have surgeon referrals and they just want the patient's scope prior to the procedure, prior to the surgery. Well, if there are no symptoms, no issues from that patient, it's really not medically necessary. Metastatic adenocarcinoma of unknown primary site when the results will not alter management. Obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude Barrett's. Symptoms that are considered functional in origin. So be aware of these policies that are out there. There's one for Anthem, Aetna, Tufts, Highmark, Humana. Just be aware of their preauthorization requirements. Medical necessity, we talk about medical necessity all the time, okay? So whether it has to do with preauthorization, whether it's a covered service or whether the payer is coming back months or years down the line and obtaining medical records and recouping because we did not meet medical necessity. Top focus areas are level four and five visits, level three hospital visits, screening versus diagnostic colonoscopy, which I'm gonna talk about later. Diagnostic EGD, already talked about it. They're also making sure that place of service is not an issue, infusion services and multiple endoscopy, which I talked a little bit about multiple endoscopy in the OIG issues. So again, diagnostic procedures require, this is so important, documentation of symptoms or abnormalities to support medical necessity for diagnostic endoscopic examination. I'm still seeing very vague indications such as abdominal pain, not covered. Anemia unspecified, not covered. All right, GERD alone, not covered. Providers need to be aware that symptoms and abnormalities are good. They're good diagnoses, they're good indications, they support why we're doing what we're doing. Pre-authorization and verification of eligibility has to be done at the time of scheduling or services may not be covered, leaving the patient or the practice. And most of the time, unfortunately, it's usually the practice that has to write off the charge. Because we didn't verify eligibility, we didn't get pre-authorization, we didn't find out that this procedure was not covered by this plan. But in scenarios like that, when the patient and provider still require it, you can have the patient sign an ABN form, an Advanced Beneficiary Notice. That allows you, so once you submit it to the payer, the payer comes back and denies it for medical necessity, you can legally bill the patient. If you did not get an ABN form signed, you cannot bill the patient, you have to write off the charge. All right, let's get into some 2021 E&M changes. So this was, I think, the biggest change this year and for our providers to get used to, and it has to deal with visits in the office. So we're just talking about office visits. So the big change, history and exam are still required, but will not be part of the scoring to determine the level of decision-making. The level will be based on decision-making or total time. There have been revision on the decision-making table for 99202 through 215. Medical necessity has to be contained within the documentation. If you are not aware of the AMA changes, because they actually did some revisions on March 9th, okay, you have to go into this website that's on the slide and any of the changes or clarifications are highlighted in like an aqua color, be sure and check those out. All right, here's your time billing. So again, your provider has two options. They can select their level of visit based on medical decision-making, or they can document a bill for total time of the encounter, which is new. Last year, it's just face-to-face. This year, it's everything in the care of the patient today on the day of the visit, such as reviewing tests, medical records, performing the visit, ordering medications or procedures, et cetera, and documenting in the record. All of those services are included in the time requirement. So the chart on this slide gives you the time thresholds effective January 1st. So 99201, that is a deleted CPT code. So if you are still billing 99201 to payers, you're not gonna get paid. It's been deleted. You've got your time thresholds for 202, three, four, and five. There is no time threshold associated with 99211. That is a nursing visit. You do have times for 99212, 213, 214, 215. Those are all your follow-up visits. All right, we're gonna look at the decision-making table. All right? And I know this is kind of a lot of information on this slide, but the next three slides tell you what level of service you're supporting by medical decision-making. The first category is number and complexity of problems addressed. Okay, so whether you're dealing with a minor problem, one stable problem, two chronic problems, et cetera. That's gonna determine whether you're straightforward, low, moderate, or high. Then you have the data category. All right, and this category changed as well. So you might have limited, moderate, or high. Okay, so this depends upon what? Review of records, ordering tests, reviewing tests, talking to an independent historian, such as a spouse, et cetera. And then you have the overall risk of the patient, whether they're minimal, low, moderate, or high. So on this slide, this gives you the examples of straightforward and low. The next slide is moderate. All right, so moderate for problems addressed, data, and overall risk of the patient. The next slide is high medical decision-making. And I'm not gonna go through this in detail just because that is, the E&M changes in and of itself is a full other separate webinar. All right, there's too much information to go through. All right, so again, under the high medical decision-making category, problem addressed, data, or overall risk of the patient. So it has to be contained in the documentation. So again, if you're doing a lot of data, you're ordering, you're reviewing, you're looking at old, you know, outside records, you're talking to other providers about the care of the patient, et cetera, you need to document that. You also should document the risk of your patient. This patient is considered high risk for this procedure because of this. All right, that will help support those higher level of visits that you're billing. All right, so we're gonna look at some examples. We're gonna look at your clinical scenario followed by what it looked like last year for decision-making and what it looks like this year for decision-making. So the first example is an established patient. IBS, which appears under control at this time, plan, continue current dose and frequency of amytsia, return in three months. Okay, so pretty straightforward visit here. So by medical decision-making, you've got one chronic problem, which is minimal, no data. We still have prescription drug management, which is moderate, but you already have two minimals, which makes the overall decision-making straightforward. This is 99212 last year. This year, you actually get credit for low problem addressed for one chronic problem. Minimal data, prescription drug management's moderate. The overall, because they're not all in the same category, you pick the one in the middle, which is low, 99213. So last year, this would have been a 212 by medical decision-making. This year, it's considered a 99213. Next example, so still an established patient, assessment IBS, which appears under control at this time, despite increased stress factors. Increased anxiety due to increased financial and work stress. Continue medications for IBS, increasing the amyotropiline dosage. She's requesting psych counseling, and I believe that this would be beneficial for her. Appointment was made with Dr. X next week, return in three months. So last year, we dealt with the number of problems, et cetera. We had two worsening problems, which are worth four points total high. Still minimal for data. Prescription drug management, which is moderate risk. So 99214, because remember, we picked the one in the middle when they're not all together, 99214. This year, the complexity of problems addressed, that is considered one or more chronic illness with exacerbation. Okay, so the IBS that's been exacerbated or had side effects, moderate. Minimal for data, moderate for prescription drug management. So you have two moderates. This is also 99214. So in the example 2, both support 99214. Number 3, this is a new patient. Left upper quadrant abdominal pain with a history of an ulcer on a meprazole per primary care with no improvement. Left lower quadrant abdominal pain has been treated for diverticulitis with no change. BENTOL gives some relief. No evidence of diverticulitis on a CT scan, but showed left renal stone. Also reviewed primary care's records and ER records. Details were in the HPI. Nausea with early satiety and indigestion. So lots of stuff going on. Plan. Continue current medications of BENTOL as needed and increase a meprazole to twice daily. Follow up with primary care regarding renal stone and left side pain. Gastric emptying scan with solids and liquids and follow up in the office in a month. Alright, so last year if we plug in the old table, we had a new problem with a workup which is automatically high. Data. So we reviewed a CT scan and ordered a gastric emptying study and reviewed records. That's three multiple tests. Moderate. Overall prescription drug management. Moderate. So you had two moderates. This is 99204. It is also 99214 this year because you've got an undiagnosed problem with uncertain prognosis which is moderate. Still considered moderate for data and prescription drug management is moderate. So we have three moderates across the board. So notice how we go through these. Some of these levels didn't change from last year to this year but the columns are a little bit different. But we still come out with most of the time the same level. 99204. So again both last year and this year decision-making support a four. Number four. This is a new patient. Chief complaint is diarrhea. Females had diarrhea for the last six months. She's new to our practice. She has up to five loose bowel movements a day. Diurnal. Nocturnal. Watery type associated with mild abdominal cramping. Not associated with fever, GI bleeds, significant weight loss. Per patient she took antibiotics for two weeks ago for an upper respiratory infection. She denies any recent travel or other family members with symptoms. She drinks coffee daily. We reviewed a previous colonoscopy. So the impression last six months of diarrhea. Family history of colon cancer and sister. She has indications for a colonoscopy. If lymphocytic colitis is proven on biopsies then we're going to start in a court. It is necessary to rule out C. diff infection and or celiac disease. So we're going to get a colonoscopy. Check celiac panel. Encourage hydration and avoid caffeine beverages. So last year again this is considered was considered a new problem with a workup which is high. Ordering labs and reviewing records was multiple moderate. Diagnostic colonoscopy was also moderate. So we have a 99204. This year we also have a level 4. But we've got new problem with uncertain prognosis for moderate. Moderate data. Diagnostic colonoscopy is considered a minor procedure. There were no risk factors identified. Unless the provider says this is a major surgery or major procedure for this patient. It's going to be assumed it's minor. So you have to make sure your providers document. This is considered a major surgery for this patient. And why? All right so right now it's just low under risk. Because minor surgery with no risk factors is low. But we had two moderates from the first two columns. So it's still going to support a 204. All right example number five. Patient has been losing weight for the past year about 12 pounds. Had a last EGD and colon. Okay patient currently on Xarelto for DVTs. Notice black stools for the past two to three months and a colt positive by primary. Denies use of iron or pepto bismol. Takes Imodium as needed. Has early satiety. Denies nausea vomiting. Denies chronic heartburn. History of MI in 2019 with occasional angina. Progressive Parkinson's since 65 years old. Denies any use of aspirin or NSAIDs. So assessment. Fecal occult positive test in melana. Possible upper GI source. Assess for neoplasms and AVMs. Weight loss. Assess for malignancy. Early satiety is assessed for gastric cancer. History of polyps. Incontinence of feces. Diarrhea. DVT Parkinson's. Inguinal hernia. History of MI. So we're gonna get labs. We're gonna order a high-risk colonoscopy. Alright we're gonna get a cardiac clearance for her Xarelto. We're gonna do a CT for the weight loss. So last year we've got extensive new problem with a workup. Extensive under data and high for diagnostic endoscopy with risk factors. This was a 99205 last year. This year it's considered a four because you have multiple chronic conditions with one new problem uncertain prognosis. All of those fall under moderate for complexity of problems addressed. We did have extensive for data but we have a minor surgery with risk factors. They didn't say that this is a major surgery for this patient. Okay so that's considered moderate. So ultimately this is a 99204. So again since endoscopy has no separate category it falls under minor surgery with risk factors since the provider did not identify it was a major surgery. Even though the patient has multiple problems the complexity is still considered moderate. So it's so important for your providers to document whether or not that procedure is minor or major and what the overall risk of the patient and procedure is. Another new patient chief complaint acid reflux. Lonnie is a 54 year old female referred by Dr. X has a history of duodenal ulcers. Has new reflux symptoms in the past year and is on protonics. Recently they've flared. Denies any dysphagia. Has never smoked and rarely drinks alcohol. Impression symptomatic GERD. Plan EGD. So new problem with a workup last year minimal data moderate for overall risk 99204. This year it's a 203. Still get moderate for the first column new problem with uncertain prognosis but there was no data and remember we have a minor surgery there was no risk factors identified. So again it is imperative that your providers document everything reviewed for data. They also need to document risk. So again this is going to fall under the minor surgery and no risk factor low risk category. Last year diagnostic endoscopy was considered moderate risk even if there were no risk factors. The last one's a consultation. Patients seen in consultation at the request of Dr. Smith with occasional right lower quadrant pain for the past two weeks. Pain is worse with bowel movements and also notes occasional black colored stools. Stool for GUIAC positive. Denies any fevers chills etc. Patient notes a history of hypertension. Family history is negative. Had a 14 review system and eight organ system exam. Alright so for right lower quadrant abdominal pain and melanin EGD and colon to rule out malignancy polyps etc. Guess what 2020 and 2021 decision-making table are the same for consults. This is a 99244. There were no changes to documentation requirements for consults even outpatient consults. Okay so you must still have a comprehensive history and exam and moderate decision-making to support a level four consult. E&M tips remember that your HPI tells the story of the patient whether new or established. Put all pertinent information in this area regarding symptoms and abnormalities and data. The impression and plan should also contain what you are addressing, what you think it might be, why you are ordering additional testing. List all conditions that you're currently managing and or that play a role in the care of the patient. If it is not documented nobody knows what you did or what you're thinking or what you're doing. It is not just to support the level of service but for medical necessity and or pre-authorization. Remember we talked about a lot about pre-authorization in the beginning of the chapter or at beginning of the webinar. All right so you have to document. Again even though the history and exam don't directly factor into the level that you're billing you still have to have a chief complaint. For example a patient that comes in with abdominal pain you would expect to see an abdominal exam performed. Another example if the patient comes in with elevated transaminase the social history specific to drugs and alcohol should be documented. It has to be what medically necessary. We have a medical legal obligation to address those things. A couple things on screening versus diagnostic colonoscopy. I know that we kind of run it over so I'm gonna give this a very quick overview. So screening versus diagnostic there it has been an update to the U.S. Preventative Service Task Force. They have addressed a draft copy for recommendations on screening to begin at age 45. So remember last year no it's actually been a couple years ago the American Cancer Society recommended screening colon for colon cancer start at age 45. Now the U.S. Preventative Task Force is also addressing this. The problem is it's still in draft status as today as of today. So my personal opinion is if this does go into effect or active status I think that is when we're gonna begin seeing payer policies be updated to start at age 45. Right now Aetna is the only policy that has changed. This is more information on the Affordable Care Act. Okay and this is again referencing high-risk screenings. So it says the U.S. Preventative Task Force guidelines only apply to routine screening. This recommendation applies to asymptomatic patients who are at average risk. So 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. So this is kind of that loophole that we talked about that the Affordable Care Act and the U.S. Preventative Task Force they address average risk screening. Okay it's up to the payer policy and their plan whether or not they cover high-risk surveillance under their screening benefits. Most payers apply the surveillance or follow-up colons to diagnostic medical benefits but that is their plan that is their policy. Screening colonoscopy the definition is so this is your average risk. It's again no personal histories typically no family histories. Frequency is every 10 years. Payers differ on this a little bit. If it's average risk screening for commercial payers they're gonna cover it at 100%. Okay 100% no financial responsibility. Medicare we're gonna put a PT modifier on the surgical claim if it converts to surgical. Patient is still responsible for that 20% coinsurance. Again high-risk screening is that patient that comes in for shortened intervals whether it be due to a family history, a personal history of adenomatous polyps, cancer, etc. All depends on the payer and the plan. So there is a Medicare screening loophole that I'm gonna quickly address and this is on the table right now. So this was actually passed and they're gonna do this in kind of phases. They're gonna phase out the 20% coinsurance that the patient has when screening converts to a diagnostic or therapeutic procedure. So currently they pay a hundred Medicare Part B pays a hundred percent for screening or surveillance if it stays that way. So there's no therapeutic. All right once it converts we put that PT modifier on there the patient still owes their co-pay. Well they're gonna phase that out to where the patient's going to start with or is going to eventually have no cost sharing. Now the problem with this is this is a very long phase out period. Okay so we're not even gonna do anything until 2023. So we so this year and next year it's still 80-20. 2023 to 2026 is 85-15% for the patient. 27-29 is 10% and then year 2030 and beyond they're gonna pay full. That's a long way out. All right for further information on this you can go to their website. We have the link it's on page 2175. All right I think this is the end of the presentation for me. I'm gonna send it back over to Michelle. She's gonna give you some closing remarks and we'll take some questions. Thanks Kristen. Again we thank you for joining us today for this ASGE webinar. So at this time we do have a couple of questions that we will ask Kristen that our audience has. Kristen the first question is when doing the time for coding do you have to place the exact time 130 to 145 or can you break it down such as five minutes reviewing chart labs imaging 20 minutes spent speaking with patient answering questions total time spent finishing chart note etc. Okay so great question. As of right now there is no requirement by the AMA by CMS by anybody that says you have to do a time in time out. So that that the latter of that example so if the provider just says I spent approximately 15 minutes reviewing records 10 in an exam and 5 documenting the chart that is appropriate. Thanks Kristen. The next question is I'm from an outpatient endoscopy ASC. There are times procedures are canceled in the pre-op prep room due to medical concerns like heart issues AFib recent chest pain blood sugar etc. I know the encounter for procedure is canceled but is there a way to capture this visit in some way since these since in these examples interventions are performed. For most of the for most the IV has been started EKG obtained nebulizer treatment may be administered blood sugar may be obtained and the doctor evaluates the patient then some type of point plans follow-ups has to be arranged. Your thoughts on that Kristen? Yes okay so there is a there is a solution to this. This is so typically when the patient comes in for a procedure in the ASC you've got two claims that you submit you submit the facility claim and the professional claim. For your facility claim you're going to build the procedure that would have been performed with a modifier 73. All right modifier 73 is for your ASC and it alerts the payer that procedure was discontinued prior to the start of anesthesia. All right based upon Medicare and most of your contracts you're still going to get at least 50% of the facility fee. For your doctor since the scope wasn't ever inserted the only thing that the doctor the professional claim would be able to report is a visit only if that physician addressed the issue and they have a separate E&M note in the system. Now you might get a you might get a denial back or a record request back because it's not the norm to submit a visit in the ASC setting but upon review the doctor will get reimbursed. Thanks Kristen. The next question says or asks should the diagnosis code for Lynch syndrome patients who have annual colonoscopies be Z12.11? It says or but they didn't provide an additional choice. So Lynch syndrome it's actually approved by Medicare for a surveillance type of a regimen but the thing is with Lynch syndrome the patient's going to come back at shortened intervals so screening the Z12.11 would not be appropriate. You're going to code the Lynch syndrome and whatever family history or personal history the patient may have to support why you're bringing it back yearly. Thanks. The second question says I have the 2021 ICD-10 opt-in book and I do not see a place where it lists it lists excluded diagnosis codes. They are going to be in the very back of the ICD-10 book so you've got two parts to the ICD-10 book. You have the index and then the tabular. The tabular where you go go in the back to find your diagnosis code that is where you're going to find the excludes one indication right underneath the diagnosis code. The front of the ICD-10 book is only where you're going to actually find the diagnosis code to then go back and reference the back for the guidelines. But yeah if you don't have that then you might want to consider ordering a different version because all ICD-10 books should have that information in them. Great, thanks Kristen. And we'll do one last question as we wrap up the webinar. This question says we seem to have some confusion in our office regarding what what to count for data elements for the new 2021 E&M guidelines. Can you explain to us what counts as a unique test that is ordered versus a unique test that is reviewed? So the AMA has defined a unique test as a test that is ordered that has a separate CPT code to be reported. So if for example you're ordering a CBC that's one test. If you're ordering a CT of the abdomen that's a different test. All right the thing that you have to keep in mind is that the AMA specifically states if you order a test at this patient encounter you do not get credit for reviewing or analyzing that test. It's one or the other. All right and then another thing that they address is that if you are billing internally for that test like let's say for a capsule for example. Since you are already billing for that test you cannot count it as any part of medical decision-making level because you're already billing you're carving out that you know additional service. Thanks so much Kristen and thank you again for joining us today. We hope this information is useful to you in your practice. If you have any questions regarding today's webinar please contact me via the email on the slide. And ASGE has designated this webinar for a maximum of 1.0 AMA PRA category 1 credits. 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 claim your credit. Your input will help us in improving on future webinars. This concludes our webinar and stay tuned for more future educational opportunities from ASGE. Thanks and have a safe great day.

coding issues

GI practices

2021

ICD-10 codes

OIG physician task force

upper endoscopy

E&M changes

time documentation

medical decision-making

coding requirements