Is your gastroenterology practice feeling a bit lost when it comes to insurance billing? Given the complexity of gastroenterology procedures, it’s easy for providers to get overwhelmed with today’s billing and coding guidelines.
If you need help understanding gastroenterology billing, we’ve got you covered. Below, learn about best practices for gastroenterology medical billing, some of the most common gastroenterology CPT codes, and tips for avoiding claim denials.
Also, check out our free webinar on how to speed up payment collection:
The Basics of Gastroenterology Billing
Insurance companies provide coverage for gastroenterology services, but to avoid denials, your billing staff will need to use the correct procedure codes and an appropriate modifier.
ICD-10-CM codes to use will vary depending on the specific procedure, diagnostic studies, or examination performed. Hundreds of codes apply to GI procedures and inpatient visits, so it’s not possible to list all of them here. Some of the most common medical billing codes used for GI services include:
- 91200: Liver elastography
- 91010: Esophagus motility study
- 91110: Gastrointestinal tract imaging, capsule endoscopy
- 91111: Digestive tract imaging, esophageal endoscopy
- 43235: Upper gastrointestinal endoscopy without biopsy
- R10.10: Upper abdominal pain, unspecified
- R14.0: Abdominal distension
- R14.1: Gas pain in the digestive system
- D12.8: Benign neoplasm of rectum
- K50.10: Crohn’s disease of large intestine without complications
The first time you treat patients, you’ll need to use the correct initial visit code. Consult these three criteria to help you decide which diagnosis codes to use for first patient visits:
- The detail of history obtained
- The development of the treatment plan
- The depth of the exam
Common codes for initial office visits include 99202, 99203, and 99204, in order of complexity.
GI providers may use modifier 59 to denote procedures that are normally separately reported. Use this code to denote:
- A different patient encounter or session, site/organ system, or medical procedure/surgery
- A separate incision, lesion, or injury
Your practice may also need to use modifier 52 or 53. Use modifier 52 to indicate reduced services and modifier 53 to indicate a discontinued procedure.
Best Practices for Gastroenterology Billing
GI practices cannot simply make up their own rules when it comes to medical billing and coding. To get reimbursement for procedures performed in a timely manner, follow these best practices:
- Make sure to use correct coding and meet documentation requirements as outlined by payer policies. If your claim submission is inaccurate or incomplete, commercial payers will deny the claim. They’ll also send denials if you haven’t outlined why a procedure is a medical necessity.
- Billing software can make life easier for your coding staff. Billing software automates the medical coding process to help ensure accurate coding for your practice.
- Invest in staff education for your billing department. Teach your staff how to stay up to date with significant changes in the coding system, as well as how to submit charges properly to commercial payers.
- Denial management is important as well. Every few months, go through your claims denials to help you identify trends and issues with specific documentation. Procedural billing audits can also tell you whether you’re hitting your key performance indicators (KPIs).
Challenges in Gastroenterology Billing
Billing staff face many challenges to ensure that claims are submitted appropriately. Challenges include:
- Staying up to date with ever-changing medical billing and coding requirements
- Changes in healthcare regulations from the Centers for Medicare & Medicaid Services (CMS)
- Grappling with denials from the insurance company
- Ensuring that a procedure is a medical necessity and thus eligible for reimbursement
- Managing the complicated patient collection process for services provided
Common Mistakes To Avoid in Gastroenterology Billing
To ensure timely payment, gastroenterology practices should train their medical billers to avoid these mistakes:
- Not submitting accurate and specific documentation with claims for services. This is the number one reason for denials. GI providers must make sure to use the proper codes for visits, diagnoses, and procedures. Billers should check all codes and modifiers for accuracy before submission.
- Failing to keep up with coding changes. The ICD-10 Coordination and Maintenance Committee updates the code list annually. It may add new codes, change existing codes, or remove codes from the ICD-10 manual. Billers should review the manual annually to check for changes.
- Billing for non-covered services. Practices must verify local coverage determinations and prior authorization requirements before performing any procedures. If the patient doesn’t have insurance coverage for a procedure (or the payer doesn’t determine a procedure to be a medical necessity), you will have to collect payment from them directly.
- Lack of communication with payers. Failing to communicate with insurance companies is a big mistake because your practice could be leaving money on the table.
The Impact of Gastroenterology Billing on Practice Revenue
Proper gastroenterology medical billing is key for the revenue of your practice. You must practice thorough revenue cycle management, which includes:
- Tracking claims (days in accounts receivable, or A/R). This refers to how many days, on average, it takes to collect payment due. It’s best to keep days in A/R below 50. Most practices aim for 30 to 40 days in A/R.
- Making sure payments are received. This is referred to as the adjusted collection rate, which represents how much you should have collected versus how much reimbursement your practice actually collected. This KPI shows how much revenue you lost due to factors such as untimely filing and uncollectible bad debt. Ideally, your adjusted collection rate should be at least 95%.
- Following up on denied claims (denial rate). This metric represents the percentage of claims denied by payers in a certain period. You’re doing well if your medical billing services department can keep your denial rate below 5%.
Other considerations for your revenue cycle include:
- Correct treatment of payment plans: these plans give a patient more time to pay for services, but this can also cause an increase in days in A/R. You may want to add a separate account for patients on payment plans to avoid muddying your calculations.
- Accounts in collection: which are written off to current receivables. For accuracy, calculate days in A/R, both with and without collection revenue.
- Credit impacts: failing to subtract credits from receivables can make it seem like your practice is doing better than it really is.
- Payer reimbursement speed: some payers reimburse more quickly than others, which could impact days in A/R.
How Weave Can Help You With Gastroenterology Billing
Sick of dealing with gastroenterology medical billing headaches? Try Weave! When Grace Family Dental put our software into action, Practice Administrator Andrea Ippolito was able to save 20+ hours on billing each week. Just think about what your GI practice could do with all that extra time.
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