4 Key Points in Gastroenterology Billing To Get Reimbursed

1
4 Key Points in Gastroenterology Billing To
Get Reimbursed
2
4 Key Points in Gastroenterology Billing To Get
Reimbursed
Reimbursement Challenges for Gastroenterologists I
nsurance reimbursements are core to any
practices 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, lets 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.
3
4 Key Points in Gastroenterology Billing To Get
Reimbursed
4 Key Points in Gastroenterology Billing To Get
Reimbursed 1. Evaluation and Management (EM)
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 (EM) 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.
4
4 Key Points in Gastroenterology Billing To Get
Reimbursed
2. Endoscopy and Procedural Billing Gastroenterolo
gists 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 todays
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.
5
4 Key Points in Gastroenterology Billing To Get
Reimbursed
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 dont 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 dont
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. Its 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 providers decision-making should
also be added as additional diagnoses to support
the higher level of decision-making.
6
4 Key Points in Gastroenterology Billing To Get
Reimbursed
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_at_legionhealthcaresoltions.com
7
(No Transcript)