Gastroenterologists provide both surgical and medical services, and that calls for a fairly broad range of billing codes to be used when it comes time make a claim for reimbursement. In gastroenterology, all reimbursement must be based on the principle of Relative Valve Units (RVU’s), which are assigned to every possible service which might be provided to a patient. These services are founded on three individual factors, including practice expense, malpractice cost, and physician work value.
The national physician fee schedule is determined by adding all three of these factors together and then multiplying by a specific conversion factor which is decided by the Centers for Medicare and Medicaid Services (CMS). Whenever claims are submitted, there must be a clear medical necessity demonstrated, otherwise there’s a good chance that a claim will be denied, or at least deferred pending further investigation. In terms of incoming revenue, any deferred or delayed claim is almost the same as a denied claim, since it results in some indefinite period of non-reimbursement.
There are four essential services which gastroenterologists perform routinely, and must choose the correct billing codes for when they wish to be reimbursed for services provided. These four areas are: evaluation and management services (E&M), endoscopy and procedural billing, diagnostic studies, and diagnosis codes. Making a mistake with the billing and coding in any of these areas will very likely result in some kind of delay in being reimbursed, or in an outright claim denial.
Evaluation and management services
E&M visits are often extremely important, given that they provide the foundation for any medical necessity regarding additional procedures or diagnostic services. These can be crucial for successful treatment of the patient, and that makes them just as important as the actual procedures, which are often deemed more important to a practice, since they generate the most amount of income. For E&M services, there are three criteria which must be met in order to validate an initial patient visit: patient history, the examination, and the treatment plan.
There are five levels of service for such initial office visits, and there are also three levels for inpatient visits. These levels must all be accurately coded and billed for, and it happens frequently enough that an un-schooled clerk will assign a guessed-at level rather than the most appropriate one. This may go unnoticed for a time, but if an audit ever becomes a reality, these guesses will be discovered and it will result in claim denials or some kind of reconciliation on past claims.
Endoscopy and procedural billing
Before you can make any kind of claim in this area, it will be necessary to justify medical necessity. Documentation must include the location of any abnormalities or lesions, method of treatment, and the reason for that method of treatment. Any special equipment used during the procedure must be fully documented in the endoscopy report, and this requires close communication between the physician and the billing staff. Ultimately, the physician is responsible for the submission of accurate claims, so it behooves the medical professional to have the billing staff well trained in how to supply appropriate and required documentation, as well as the correct medical billing codes for every possible procedure.
As always, medical necessity must be demonstrated in order to submit a claim for any kind of diagnostic testing. Abnormal lab tests, unusual symptoms, and signs of illness do warrant the need for continued examination, and these are generally the most important factors signaling the need for further diagnostic testing. It will be necessary to clearly indicate the results of any diagnostic testing, and for any procedures which were necessary. A plan or recommendation for treatment must also be included and indicated by the appropriate billing codes when submitting a claim.
Codes for diagnosis come directly from ICD-10-CM, and the assignment of these codes is the next most important step after a patient visit, a diagnostic study, or a procedure. These billing codes provide justification for medical necessity of services provided, so it is crucial that the correct codes are used. Since there are nearly 72,000 codes which might be used in this area, it is essential for office personnel to be properly trained in the correct usage of the codes. Getting reimbursed for all services provided requires a good amount of education and training for all staff members, in addition to close communication between physician and office people.