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4 Key Points in Gastroenterology Billing To Get Reimbursed

4 Key Points in Gastroenterology Billing To Get Reimbursed

Reimbursement Challenges for Gastroenterologists

Insurance reimbursements are core to any practice’s successful day-to-day operations and Gastroenterology practices are no exception. However, Gastroenterologists are not trained for this business side of medicine i.e., medical billing and coding. They come out of training with the knowledge to treat patients but with little or no knowledge of how to get reimbursed for their services. Plus, they want to spend most of their time in patient care rather than in such administrative activities. In this article, we focussed on 4 key points in Gastroenterology billing that will help your practice to get reimbursed, timely and accurately. Before discussing these key points, let’s understand the basics of insurance reimbursements for any healthcare practice.  

Insurance Reimbursement Basics

The insurance reimbursements are majorly based upon Relative Value Units (RVUs) assigned to every service provided. Any physician services depend upon three factors i.e., physician work value, malpractice cost, and practice expense. These three factors are added together and multiplied by a conversion factor assigned by the Centers for Medicare & Medicaid Services (CMS) which creates the national physician fee schedule. Each Medicare carrier has localities, and there is another percentage that is multiplied based on geographic location, which will finalize the approved amount for each service. While third-party/ commercial insurance carriers most commonly base their contracts on the Medicare Fee Schedule. Know that even though they have Medicare rates as a base, each practice and insurance carrier relationship is different. Medicare and commercial insurance carriers will often have local coverage determinations (LCDs) for procedures and testing that include indications and restrictions along with approved diagnosis codes.

4 Key Points in Gastroenterology Billing To Get Reimbursed

1. Evaluation and Management (E&M) Services

As the name evaluation and management indicates, these codes are applicable to visits and services that involve evaluating and managing patients. Examples of E/M services include office visits, hospital visits, home services, and preventive medicine services. Medicare, Medicaid, and other third-party insurance carriers accept E/M codes on claims that physicians and other qualified healthcare professionals submit to request reimbursement for their professional services. Small E/M coding mistakes can cause major compliance or payment issues if the errors are repeated on a regular basis. Insurance carriers often see that visits are chosen by ‘guessing’ the level, which leads to choosing either a lower or higher level of E/M service than what was actually provided.

Sometimes Gastroenterologists are instructed that E/M services are not that important since procedures are the major source of revenue for the practice. However, Gastroenterology practices are visit-driven, and the initial visits are often worth more RVUs than some procedures. Evaluation and Management (E&M) services are also important as they form the base for the medical necessity of any additional procedures and diagnostic services required in order for the successful treatment of the patient. To prove medical necessity and reimbursement for these services, those involved in the coding process (including Gastroenterologists) need to stay up to date on E/M coding rules.

2. Endoscopy and Procedural Billing

Gastroenterologists will often use multiple techniques when treating different areas within the gastrointestinal tract. All must be documented properly including the location of lesions/abnormalities, method of treatment/removal, and the reason(s)/indication(s) for those procedures. There may be different instruments used in the colon (for example, snare in the sigmoid colon or biopsy forceps in the transverse colon). These may be separately reported with an appropriate modifier to indicate that these services were performed for different lesions/abnormalities. Gastroenterologists are also responsible for accurate and specific documentation and guiding billing staff for claim submission. They along with the whole coding staff need to have an open line of communication to make sure that everything is submitted appropriately according to insurance carriers’ reimbursement policies.

To succeed in today’s billing environment the gastroenterologist should surround their practice with staff, resources, and education. Experienced skilled staff, preferably a Gastroenterology certified professional coder should be employed. These certified coders can bring advanced coding skills to your Gastroenterology practice, which allows increased proficiency. Provide the necessary resources for staff. The latest coding material is crucial to the financial success of the practice. ICD-10 and Correct Coding Guide are the bare basics of the resource material available to staff. Maintaining a library of resource material (i.e., Medicare bulletins, and managed care newsletters) helps your billing staff with the necessary tools to carry out their duties. It is imperative that your coding team attends all Medicare-sponsored workshops in addition to gastroenterology-specific coding seminars.

3. Diagnostic Studies

Medical necessity/indication for the testing must be documented in order to submit charges for diagnostic studies. The terms ‘rule out’ and ‘suspect’ don’t completely give coders the reason why a physician suspects the patient might have a condition. Usually, abnormal lab tests, signs, and symptoms will often warrant the need for further investigation, and these are the most crucial indications for testing. Not only is this important for diagnostic studies but also for procedures. Make sure that the interpretation of the test results is clear along with a plan/recommendation(s).

Medical necessity for testing must be documented in order to submit charges for diagnostic studies. Your notes with remarks like ‘rule out’ or ‘suspect’ don’t completely give coders the reason why you suspect the patient might have a condition. Normally, abnormal lab tests, signs, and symptoms might often warrant the need for further investigation. Make sure that the interpretation of the test results is clear along with a plan or recommendation for the next steps.

4. Diagnosis Codes

Assignment of procedure codes per the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) is the next and most important step after a visit, diagnostic study, and/or procedure. It’s not easy to choose accurate diagnosis codes as there are nearly 72 thousand ICD-10-CM codes to choose from. Diagnosis codes support medical necessity for the services provided, and the correct diagnosis code is vital to the successful submission and payment of a claim. Comorbidities that impact the provider’s decision-making should also be added as additional diagnoses to support the higher level of decision-making. Up to 12 diagnosis codes can be assigned to any type of service provided. If specific information is not in the documentation for your staff to access, payers will often deny certain lab and radiology studies, as well as some procedures.

Getting reimbursed for Gastroenterology billing requires attention to detail and communication with your entire billing team, including all providers. Make sure that your team is educated on current Gastroenterology billing and coding guidelines along with various payer reimbursement policies. If you are having issues forming a billing team, contact us for your Gastroenterology billing and coding requirements. Legion Healthcare Solutions is a leading medical billing company providing complete Gastroenterology billing and coding services. Our team of experts ensures that you will receive timely and accurate insurance reimbursements for every insurance carrier. To know more about our Gastroenterology billing and coding services, contact us at 727-475-1834 or email us at info@legionhealthcaresoltions.com

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