4 Key Elements of GI Billing

1. Visit our website: Click here Follow us: 4 Key Elements of GI Billing Effective billing practices are crucial in gastroenterology practices to ensure accurate reimbursement and successful claim submission. This article explores the four key elements of GI billing: Evaluation and Management (E&M) services, endoscopy and procedural billing, diagnostic studies, and diagnosis codes. Understanding these elements is essential for providers, coding staff, and billing teams to navigate the complexities of medical necessity documentation, code assignment, and claim submission. By emphasizing the importance of each element and highlighting the challenges involved, this article aims to promote knowledge and collaboration within GI practices to optimize billing processes and financial outcomes. 4 Key Elements of GI Billing Gastroenterologists perform and interpret four primary services: 1. Evaluation and Management (E&M) Services For any initial visit with patients, there are three essential criteria to meet: obtaining patient history, performing an examination, and developing a treatment plan. Office visits have five levels of service, while inpatient visits have three levels. The selection of the appropriate level of service relies on the decision-making aspect of the visit, considering that the documentation requirements are fulfilled. However, choosing the correct level can be challenging without a proper understanding of E&M criteria. Copyright © Medical Billers and Coders. All Rights Reserved Call now 888-357-3226 (Toll Free) info@medicalbillersandcoders.com 1

2. Visit our website: Click here Follow us: It is not uncommon for auditors to observe visits being determined through guesswork, resulting in the selection of a lower or higher level than what was actually provided. Some providers may underestimate the importance of E&M services, considering procedures as the primary revenue source. Nevertheless, in GI practices, visits play a significant role, and initial visits often carry more RVUs than certain procedures. The E&M visit is crucial, serving as the foundation for establishing medical necessity for additional procedures and diagnostic services necessary for effective patient treatment. 2. Endoscopy & Procedural Billing In endoscopy and procedural billing, it is crucial to document medical necessity to facilitate the submission of charges. Gastroenterologists often employ multiple techniques when treating various areas of the gastrointestinal tract. Documentation should include details such as the location of lesions/abnormalities, the method of reasons/indications for the procedures. In the colon, different instruments may be used for different areas (e.g., snare in the sigmoid colon, biopsy forceps in the transverse colon). These services can be reported separately with appropriate modifiers to indicate that they were performed on distinct lesions/abnormalities. treatment/removal, and the However, to bill for each procedure, all relevant information must be documented in the endoscopy report. The responsibility lies with the physician to ensure accurate and specific documentation and to relay the charges to the billing staff for claim submission. A team approach is vital for a successful practice, necessitating open communication between physicians and coding staff to ensure proper submission according to payer policies. The billing staff should promptly inform physicians/providers of any significant changes as they occur. It is important to note that ignorance of payer policies is not considered an acceptable excuse when payers investigate claims and potential recoupment of funds paid. 3. Diagnostic Studies In diagnostic studies, it is essential to document the medical necessity and indications for testing to facilitate the submission of charges. Using terms like “rule out” or “suspect” alone does not provide coders with sufficient information about the physician’s reasoning behind suspecting a specific condition. Typically, abnormal lab tests, signs, and symptoms justify the need for further investigation, making them crucial indications for testing. This importance extends not only to diagnostic studies but also to procedures. It is crucial to ensure that the Copyright © Medical Billers and Coders. All Rights Reserved Call now 888-357-3226 (Toll Free) info@medicalbillersandcoders.com 2

3. Visit our website: Click here Follow us: interpretation of test results is clear and accompanied by a well-defined plan or recommendation(s). Clear documentation in these areas helps support the medical necessity of the tests and procedures performed. 4. Diagnosis Codes After a visit, diagnostic study, or procedure, the next crucial step is assigning codes according to the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM). These codes play a significant role in supporting the medical necessity of the services provided, and the specificity of the diagnosis code is essential for successful claim submission and payment. When ruling out more significant diseases or diagnoses, signs and symptoms can be valid code choices as they justify the need for a work-up to determine the underlying cause. Additionally, comorbidities that impact the provider’s decision-making should be included as additional diagnoses to support a higher level of decision-making. Up to 12 diagnosis codes can be assigned to any type of service. This also applies to obtaining preauthorization for services such as lab tests, radiology studies, GI diagnostic studies, and procedures. It is crucial to ensure that specific information is documented, as payers often deny certain lab and radiology studies, as well as certain procedures, if the necessary information is missing. With a vast selection of 71,932 ICD-10-CM codes, finding the specific code can be challenging within electronic health records and billing systems. To summarize, the proper understanding and application of Evaluation and Management (E&M) criteria, accurate documentation of endoscopy and procedural details, clear indication and interpretation of diagnostic studies, and precise assignment of diagnosis codes are key elements of GI billing. By focusing on these four key elements, GI practices can enhance their revenue cycle management, streamline operations, and ultimately deliver quality care to their patients. About Medical Billers and Coders (MBC) Medical Billers and Coders (MBC) is a trusted and reliable gastroenterology billing company that specializes in providing comprehensive billing services tailored to the unique needs of gastroenterology practices. With our expertise in medical coding, documentation requirements, and billing regulations specific to the field of gastroenterology, MBC ensures accurate and efficient claim submission and reimbursement. By partnering with MBC, gastroenterology practices can rely on their expertise and industry knowledge to streamline their billing processes, increase efficiency, and focus on delivering high-quality care to their Copyright © Medical Billers and Coders. All Rights Reserved Call now 888-357-3226 (Toll Free) info@medicalbillersandcoders.com 3

4. Visit our website: Click here Follow us: patients. For further information about Gastroenterology billing services, please reach out via email at info@medicalbillersandcoders.com or by calling 888-357-3226. Copyright © Medical Billers and Coders. All Rights Reserved Call now 888-357-3226 (Toll Free) info@medicalbillersandcoders.com 4