With the ever-changing eating habits and lifestyle alternatives, people would have been exposed to too many digestive issues including acid reflux and food poisoning but they rarely visit a gastroenterologist for their condition in their lives. According to an estimation, around 66.4 million primary diagnoses of digestive diseases result in each year in the United States (including hospital emergencies, physicians’ offices, outpatient facilities, etc). Because of this, billing gets challenging for billers to a range of payers. With these challenges, billers should know how to bill for medical gastroenterology effectively to receive reimbursements in a timely manner.
How to bill for medical gastroenterology?
You might have seen a range of billing methods, but medical invoicing is stuffed with different requirements which require a lot of experience and coding knowledge.
A firm or a billing service must have an experienced medical billing team having complete knowledge of the criteria and systems that insurance companies use to evaluate the medical claims of a provider or the healthcare organization. Furthermore, when it comes to gauging any specialty in billing, such as gastroenterology, the challenges become more prominent and it gets even more difficult to meet the effectiveness required.
Gastroenterology practices and healthcare centers do not always afford to leave the revenue uncollected or drain out by leaving their medical billing management to freelancers and medical billing agencies who are not experts in gastroenterology billing or invoicing. Several reasons are there for it, one of them being the continuous surge of medical equipment used and the treatment provided in gastroenterology.
Oftentimes, it also has been seen that organizations that boast about handling gastroenterology medical billing efficiently, most of the time they outsource the billing service to providers who work remotely or operate the system from home. These medical billing services providing companies may perform better, but there’s a significant risk of revenue loss as the lack of company collaboration and less necessary training opportunities leave them behind in meeting revenue goals that normally gastroenterologists have.
Some other crucial steps in billing for gastroenterology include answering procedural and technical questions and diagnosis and appealing for the rejected claims timely that hold a big revenue for a gastroenterologist. One must need a wide experience in the field to accumulate the required information and this can only be done by spending a good time working under a gastroenterologist.
For competent endoscopy and gastroenterology billing, the ability to track down underpayments is necessary. Because the capability of many medical organizations’ billing software often falls behind when it comes to tracking gastroenterology underpayments. This creates a major setback because efficient tracking of unpaid bills can escalate the revenue of a gastroenterologist from 7 percent to 10 percent.
When tracking patient bills gets challenging, the patient collection gets affected and yet a big void is created in the revenue cycle over time. Owing significant outstanding bills results in intricate billing procedures or EOBs, which can be discussed prior to billing patients who do not decode the bills without external clarification. Here, the responsibility of the billers of practices like gastroenterology gets more involved.
Apart from medical invoicing, these data gathering and tracking underpayments can be efficiently performed by gastroenterology medical billing agencies. Having not much experience in handling such issues, businesses have to see a reduced bill collection and run a risk of upsetting patients who remain unaware of the charges till the very end.
Gastroenterology Medical Billing and Coding
Gastroenterology CPT codes;
Healthcare organizations have launched over 72,000 ICD-10 CM codes related to gastroenterology. This is why without experience in using them and having proper knowledge, choosing the right one in a computerized medical system and medical records for a specific diagnosis can be tricky. Professional development and updated training are crucial for a gastroenterology medical billing department to make it efficient while dealing with the gastroenterology ICD- 10 CM codes.
To start off with, here are some useful and common ICD-10 CM codes used for gastroenterology;
Allergic and dietary gastroenteritis and colitis, K52.2
Other noninfectious gastroenteritis and colitis (K52.89)
Diarrhea, nonspecific R19.7
OT/Multi-Site Abdominal Pain:
R10.10 Unspecified upper abdominal pain
Pelvic and perineal discomfort (R10.2)
R10.30 Unspecified lower abdominal pain
Neo Rectum/Anus Benignum:
D12.7 Rectosigmoid junction benign neoplasm
D12.8 Rectal benign neoplasm
D12.9 Anus and anal canal benign neoplasm
Abdominal distension (R14.0) (gaseous)
Neo Lg Bowel Benign:
D12.0 Cecum benign neoplasm
D12.1 Appendix Benign neoplasm
D12.6 Colon benign neoplasm, unspecified
Common CPT Codes for Gastroenterology
91200 Liver electrography
91010 Esophagus motility study
91110 GI tract imaging, capsule endoscopy
91065 Breath hydrogen/methane test
91122 Anorectal manometry
91035 Gastroesophageal reflux test w/electrode
91037 Esophageal function test w/electrode
91120 Rectal sensation test
91038 Esophageal function test, >1 hour
91034 Gastroesophageal reflux tests
91040 Esophageal balloon distention tests
91299 Gastroenterology procedure (other)
91112 GI wireless capsule measurement
91020 Gastric motility studies 516 0.10%
91111 GI tract imaging, esophageal endoscopy
Gastroenterology Medical Billing Tips to Consider
To receive exceptional gastroenterology practice experience, providers need to consider these acceptable gastroenterology medical billing tips.
1- Collaborate and communicate
In order to get everything done efficiently and correctly with payer compliance, coding staff, and doctors must create an open environment of communication. As far as billing for gastroenterology is concerned, the physician is the person responsible to provide specific paperwork and correct information about the returning orders to the billing department to submit a claim. If there’s a need for a change in code or invoice, it must be communicated with the provider and the concerned department as early as it is possible.
2- Bill for E&M services efficiently
When patients visit any gastroenterological clinic, the first procedure conducted for them is evaluation and management. To perform any further procedure, it is mandatory to meet three specific requirements that include the history of the patient, the diagnosis, and the treatment plan. When it comes to billing for such gastroenterology clinical visits, billers need to catch five levels of clinical appointment care and three levels for appointments for inpatients. This is why it is necessary to choose the E&M levels for gastroenterology procedures efficiently while billing.
3- Diagnostic language
Once there’s a need for adding costs for diagnostic studies in the invoice, the medical urgency required for testing must be verified. Anomalous lab tests, symptoms and indications usually provoke additional verification which makes them a major indicator for testing while billing. Ensuring that the diagnosis and test codes are properly used and any other strategy and advice which is being used during the testing and treatment are coded efficiently to make further claims.
Tips for billing and coding for gastroenterologists
– Proper documentation is the first step
Providers need to ensure accurate code, proper documentation, and medical necessity for successful billing. Incomplete medical conditions and incorrect documentation can lead to claim denials, and rejection for lab testing, diagnostics, medication, diagnostics, and other surgeries and procedures.
Although the tests and diagnosis are Localized Coverage Determinations (LCDs) from commercial payers and Medicare along with approved diagnostic codes. Gastroenterology Hepatology studies say that paperwork for procedural billing for endoscopy must include methodology and procedures performed to cure the digestive tract, the techniques used to treat/remove, the positions of abnormalities in the digestive tract, and the reasons and indications involved in the procedures including medical necessity.
When bills are prepared, all the required facts must be listed in the reports of endoscopy to record expenses for each surgery. Tools and equipment used in the surgery(ies) should also be recorded using different modifiers separately to specify their use for different abnormalities.
Similarly, while billing for procedures and studies medical indications and necessities for the procedure and testing must be documented. One of the most important indicators or advance warnings is abnormal symptoms, blood tests, and signs against the procedure.
To avoid these red flags, providers must ensure that any recommendation and evaluation of test results should be recorded in the billing documentation.
Understanding and following E/M guidelines
Medical billing and coding guidelines are updated each year. In order to maximize reimbursements, it is necessary to understand the appropriate recording of patient visits, evaluation of diseases, and administration of medical procedures while coding. To provide E/M coding, clinical decision-making abilities, and time management are two major factors.
In the 2021 update to coding guidelines, CPT changed the definition linked with the codes from 9920 to 99215 which previously was ‘average face-to-face time ‘and now changed to ‘time consumed on the contract date/day’. The reason behind this change is to make coding for time spent clearer for billers when multiple practitioners are involved.
To consider the time spent, the following are some activities that should be considered;
- Individual information collecting
- Preparing to operate on the patient
- Taking patient examination
- Analyzing gathered information
- Educating/counseling patients and family
- Communication with healthcare referrals and experts
- Treatment records
- Obtaining prescriptions, procedures, and tests
- Coordination of care
- Conveying and interpreting outcomes and benefits of the procedure to the family and patient individually.
It is important to keep in mind that when time is the one factor that influences the end result, MDM and background exams bear no code for the encounter.
Modifiers and their appropriate application
The commonest gastroenterological coding errors are the discrepancies between the modifiers 51 and 59 which are used for multiple and single operations respectively. The modifier 59 is used to cover a range of services performed, however, they are usually served different purposes. According to the explanation of modifier 51, one practitioner will perform multiple functions other than E/M in one session or visit. When the functions of a doctor are listed in RUV order, modifier 51 is often used to record the second and the following consecutive procedures to payers. However, the modifier will not be associated with the principal procedure depending upon the medical procedure implemented to treat the patient’s illness.
Modifier 59, known as Distinct Operational Service – restricts the billers to keep the operations and procedures performed on the same day separately with distinct values. In addition, modifier 59 can be applied to several procedures performed in a single day of service, on another anatomic site, for the continuation of the previous procedure, for separate incisions, surgery for a damaged body part.
Applying the correct ICD-10 codes
The use of ICD-10 codes demonstrates the services provided. Medical billing and coders should use the exact ICD codes for the services documented similar to the clinical records that use the most precise clinical diagnosis while billing. The use of correct CPT and ICD-10 codes is mandatory for timely submission and reimbursement. When a physician does not reach a diagnosis or the cause of the comorbidity they must be billed by coding as accurately as possible consisting of signs and symptoms, indications, test findings, and the reason for the interaction. Other intricacies can also be coded to indicate the presence of the disease and to help identify the highest level of accuracy.
Challenges and key factors of gastroenterology medical billing
It is not a secret anymore that medical providers including gastroenterologists have to keep the billing and coding guidelines updated and follow payer-specificity to sustain an economically sustainable and compliant practice. No matter what practice, coding and invoicing for medically provided services demand a range of skills and a wide experience to have optimal compensation.
Invoicing for colonoscopies, investigations, and agility into GI function, along with acceptable administration, documentation, and assessment process, gastric cancer screening, and GERD medication using qualifiers and modifiers such as -59, -51, and -26, are some of the examples of complex gastroenterology medical billing.
In addition, tracking for underpayments and retaining customers by educating how the bills are made, is necessary for endoscopy and GI billing. However, accounting professionals and invoicing software often do not meet this necessity. For this reason, gastroenterology practices lose significant underpaid revenue each year.
When it comes to billing and coding for gastroenterology practices or any healthcare service, using the right strategy and wisely coding is everything that is required. For this, it is necessary to hire a team of professionals experienced in coding and billing to receive accurate and timely compensation.