So, the billing process, how can you get reimbursement? If you just do the cases, you will find out that you're going to have a good amount of rejection. So, I learned after a while that if you are in a system that's specifically our view-based system, and you tell them I'm doing a procedure that's not having a CBT code, they are going to use something called, they have a reference book, and they look at the unlisted code, and they see that the unlisted code equivalent 6R view. That's how it is right now based on university practices. If you're going to do colonic ESD or esophageal ESD for 6R view, that's very bad. That's even less than ERCP. You cannot justify that. So, in order to justify it, they may tell them, you know what, I am generating more money from this procedure, but in order to generate more money, you have to make sure that the insurance will pay for it, and for insurance to have to pay for it, you have to go through this process that I'm going to explain to you right now. Number one, you have to write, in every patient I do, I write a letter of medical necessity. That letter is prepared. If it is esophageal adenocarcinoma, different than colon polyp, and the letter will say the following, patient blah, blah, blah, has this condition, the standard treatment by surgery is this, we're doing ESD because it does this, and this, and that, and that's cost saving for the insurance, and I write that in the letter of medical necessity, and we explain everything about the ESD in the letter, and then we send the documentation of the medical record with it, and we also send additional data about ESD efficacy, and the one that I suggest that you guys use is the AGA clinical updates, and it was published in 2019, and it's showing the indication of the ESD, and people respect clinical practice updates. It is, we don't have guidelines yet for ESD in the United States, but that's as close as it can get to guidelines, which is the AGA clinical practice update about ESD of 2019, and I'm going to show it at the end, too, for my discussion. So I send them that, and it's very hard to argue with the clinical practice updates. Then what I'm saying right now is what I do in my practice, and I want to stress again that that's not the opinion of the ASGE. That's what I do for my practice, and it's just a suggestion for you. I use generic code, and this unlisted code that I'm using, 43499 for esophagus, 43999 for stomach, and 45399 for colon, and then I put the regular AGD and colonoscopy code. Then you will have two pathways. If you are going to Medicare, you cannot do anything. You just will send all this stuff, but you cannot ask for preauthorization, predetermination. You do the case, and you send all this documentation to them at the end, but if you have private insurance, then I submit for something called voluntary predetermination request. So the insurance company will tell you, just do the procedure, and we'll talk after, and you tell them, nope, I don't want to go through this route. I don't want to even get preauthorization. I want to get predetermination request. So this voluntary predetermination request is that it means that you are telling them, I want 100% reassurance from you that once I do this procedure, I'm going to be paid for. The problem with doing voluntary predetermination request is that it takes at least between 15 to 30 days, and if you are doing colonic polyps, mostly benign, this would be good. If you are doing esophageal cancer, you can just expedite it right away to get it in the 15 days, but it's not going to be done next day. It's not going to be done even within a week. The minimum is two weeks. So when you do this voluntary predetermination, you're going to end up with two results. Either they accept to do the case, and they tell you you are approved, then you schedule it. Or they will say, we reject it, and you can go for peer-to-peer. And in this situation, I do the peer-to-peer with the physician, and I will tell you most of the time, they will accept it. So you will ask me, why I would go through this painful route of doing all of this? And the reason is, if I really just do this procedure with pre-authorization without getting predetermination, I may get 50% rejection rate, and there will be no evidence of how much money we generate. Because I am doing the colonic ESD for 12 RVUs or 14 RVUs, and that's based on how much this procedure is paying for. And when we bill, we bill by the hours. So I will write in my note, I spent 100 minutes, I spent 80 minutes doing that, and we try to bill with this unlisted code two to three times the rate of EMR. So at the end of the day, you're going to be getting the equivalent money. Like if you look at how much you get from EOS, and you look at how much you get from ESD procedure, you will find that the equivalence around 12 to 14 RVUs. And this is what I get from my procedure within my system, based on my history of collection, and how I built a good history of collection is by using that system that I will only do the procedure that are approved for predetermination. Obviously, if you are still at the training stage, and you're trying to find one or two lesions to do, that's fine, you don't have to do that. But once you have 50% of your practice as this patient, you cannot afford doing patient who are not approved for the procedure. For more information, visit www.FEMA.gov

billing process

reimbursement

medical procedures

colonic ESD

esophageal ESD