Maximize Reimbursement in the Face of CMS Payment Cuts with Gastroenterology Billing Services

by | Last updated Jun 9, 2023 | Published on Jun 27, 2016 | Specialty Billing

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Many gastroenterologists are utilizing professional medical coding services to manage challenges relating to the proper use of Initial Observation Care time component codes, prolonged services codes, and appropriate modifiers. Moreover, with the following CMS payment cuts affecting gastroenterology practice revenue, more and more practices are relying on gastroenterology medical billing and coding companies to maximize reimbursement.

  • Medicare has cut reimbursement for colonoscopy up to 17 percent, which has affected access to care. Colonoscopy is a life-saving procedure in that helps greatly in colon cancer prevention.
  • CMS met only .23% of the 1 percent net reduction target for misvalued codes in 2016, resulting in a .77 percent reduction in the Physician Fee Schedule to all services.
  • Incomplete colonoscopies are paid at one-half the value of a completed procedure with the same code.
  • Though there were no changes made in the Physician Quality Reporting and Value-based Payment Modifier, in 2019, there will be adjustments to payment for quality reporting and other factors under the Merit-Based Incentive Payment System and Alternative Payment Models, required by the Medicare Access and CHIP Reauthorization Act.
  • ASCs will have to successfully participate in the ASCQ program, failing which they will get 2 percent lower Medicare reimbursement.
  • CMS has aligned colorectal cancer screening codes G0105 and G0121 payment and increased payment for services to the same level as CPT code 45378. However, under the restructuring, facility payment and ASC payment for colonoscopy codes is 3 percent and 2 percent lower respectively.
  • Nine clinical families, including GI for the Ambulatory Payment Classifications, have been restructured. While the hospital outpatient services conversion factor has been lowered 0.3 percent, ASC payment has been revised upward by 0.3 percent using the consumer price index.

The rules and regulations of insurance companies with regard to insurance authorization have also become tighter. Many insurance companies now have radiology benefits managers and pharmacy benefits managers that physicians need to go through to review and get authorizations for CT Scans, MRIs or complex radiology tests and also to make prescriptions.

All these changes can seriously jeopardize revenues of gastroenterology practices and affect Medicare beneficiaries, and experts are calling for federal action to remedy the situation.

By outsourcing medical billing and coding, physicians can benefit from professional support for ICD-10 coding, electronic claim submission, denial management, payment posting, collections and continual follow up on unpaid and underpaid claims. This is the best way to take care of the business aspect of their practice. The expert billing staff in such companies is knowledgeable about complex gastroenterology billing codes and rules, gastroenterology-related terminology, coding for surgical procedures, and code variations related to multiple procedure rules. They are also up to date on payer rules and regulations. Such expertise will go a long way in ensuring error-free coding and claim submission for maximum reimbursement.

  • Natalie Tornese
    Natalie Tornese
    CPC: Director of Revenue Cycle Management

    Natalie joined MOS’ Revenue Cycle Management Division in October 2011. She brings twenty five years of hands on management experience to the company.

  • Meghann Drella
    Meghann Drella
    CPC: Senior Solutions Manager: Practice and RCM

    Meghann joined MOS’ Revenue Cycle Management Division in February of 2013. She is CPC certified with the American Academy of Professional Coders (AAPC).

  • Amber Darst
    Amber Darst
    Solutions Manager: Practice and RCM

    Hired for her dental expertise, Amber brings a wealth of knowledge and understanding of the dental revenue cycle management (RCM) services to MOS.

  • Loralee Kapp
    Loralee Kapp
    Solutions Manager: Practice and RCM

    Loralee joined MOS’ Revenue Cycle Management Division in October 2021. She has over five years of experience in medical coding and Health Information Management practices.