Know the Right Use of Modifiers 51 and 59

Know the Right Use of Modifiers 51 and 59

Correct and appropriate use of modifiers is important to file accurate claims and thus receive correct payments. Modifiers enable surgeons to effectively meet payment policy requirements established by the insurers. Wrong use of modifiers is one of the most common GI coding mistakes. In gastroenterology coding and in other specialty coding, when the same surgeon performs multiple procedures in the same operative setting, often there is confusion about using modifier 51 (Multiple procedures) or modifier 59 (Distinct procedural service).

Known as surgical modifiers, modifiers 51 and 59 are both used when multiple services are performed during a single encounter. However, they serve different purposes.

Modifier 51 can be used to report multiple surgeries performed on the same day, during the same surgical session. It is used to identify the second and subsequent procedures to third party payers. The modifier would be applied to any secondary procedures performed. It can be used to document two procedures in two different coding categories performed on the same day, just like EGD and colonoscopy.

To report this modifier right, the coder should list the procedure with the highest RVU (highest paying) first, and use modifier 51 on the subsequent service(s) with lower RVU (lowest paying).

The American Society of Anesthesiologists says that Modifier 51 applies to:

  • Different procedures performed at the same session
  • A single procedure performed multiple times at different sites
  • A single procedure performed multiple times at the same site

It is not to be used when a procedure is performed along with an Evaluation and Management (E/M) service. There are instances where multiple procedures are performed but modifier 51 is not appropriate. Modifier 51 is not appended to add-on codes like CPT code 64462.

Modifier 59

Modifier 59 refers to Distinct Procedural Service which indicates that a procedure is separate and distinct from another procedure provided on the same date of service. According to CMS, “Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.” Modifier 59 helps to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. It can be used for different session or encounter on the same date of service and different procedure, distinct from the first procedure.

To use this modifier, provider’s documentation has to support different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury, which is not ordinarily encountered or performed on the same day by the same individual. CMS recommends this modifier should only be used to identify clearly independent services that represent significant departures from the usual situations described by the NCCI edit.

CMS reports other three specific appropriate uses of modifier 59, as –

  • for two services described by timed codes provided during the same encounter only when they are performed sequentially
  • for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure
  • for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure

Coders must make sure not to use modifier 59 when a more appropriate modifier is available. Earlier, modifiers XE, XP, XS and XU were used along with modifier 59. But now, these modifiers are not required but may be used instead of modifier 59 when appropriate.

Modifier 51 vs Modifier 59


Modifier 51

  • Multiple procedures
  • Extra procedure in same session
  • Extra procedure in different site

Modifier 59

  • Distinct procedures
  • Separate procedure in different sessions
  • Distinct procedure in different site

While there are differences in usage between modifier 51 and 59, there are certain similarities too.

Both the modifiers –

  • should not be applied to an E/M service
  • have payment implications

Modifier 51 impacts the payment amount, and modifier 59 affects whether the service will be paid at all. Medical billing companies as well as medical practices should take effort to use the right modifiers on the medical claims and thus prevent claim denials and reimbursement issues.

Expanding Role of Gastroenterologists in Obesity Management

Expanding Role of Gastroenterologists in Obesity Management

Obesity is a serious medical concern. According to the World Health Organization (WHO), worldwide obesity has nearly tripled since 1975. World Obesity Day is observed annually on October 11 to highlight the environmental and medical factors contributing to high obesity rates. Overweight and obesity are amongst America’s most pressing public health problems. Obesity increases the risk for serious diseases such as cancer, diabetes, heart and disease. It is also a risk factor for many gastrointestinal conditions. Treating obesity is as complex as the condition itself is. In fact, in recent years, gastroenterologists have been increasingly involved in treating obese patients. A gastroenterology medical billing company can help gastroenterology practices manage the coding and billing for these services.

Obesity and Body Mass Index (BMI)

The Centers for Disease Prevention and Control (CDC) defines obesity as follows: “Weight that is higher than what is considered as a healthy weight for a given height”.

Physicians use body mass index(BMI) and waist circumference to determine if a person is at an appropriate weight for their age, sex, and height. According to the CDC, a BMI between 25 and 29.9 indicates that a person is overweight, while a BMI of 30 or over suggests that a person may have obesity.

The CDC adult BMI chart is as follows:

  • BMI less than 18.5 – underweight
  • BMI18.5 to <25 – normal
  • BMI 25.0 to <30 – overweight
  • BMI 30.0 or higher – obese

A report from the American Medical Association had cited a study indicating that the nation’s obesity rate was close to 40 percent in 2018, a 5 percent increase from the range of 34–35 percent between 2005 and 2012. Obesity is taking its toll on adults as well as children.

Coding for Obesity and BMI

When coding for obesity, both the obesity diagnosis as well as BMI should be coded.

ICD-10 Obesity Codes:

  • E66.1 Drug-induced obesity
  • E66.2 Severe obesity with alveolar hypoventilation
  • E66.3 Overweight
  • E66.8 Other obesity
  • E66.9 Obesity, unspecified

BMI Codes Z68

  • Z68.20 – Body Mass Index (BMI) 20.0-20.9, adult
  • Z68.25-29.9 Body mass index (BMI) 25-29.9, adult
  • Z68.30-Z68.39 Body mass index (BMI) 30.0-39.9, adult
  • Z68.4 Body mass index (BMI) 40 or greater, adult
  • Z68.41 Body mass index (BMI) 40.0-44.9, adult
  • Z68.42 Body mass index (BMI) 45.0-49.9, adult
  • Z68.43 Body mass index (BMI) 50-59.9, adult
  • Z68.44 Body mass index (BMI) 60.0-69.9, adult
  • Z68.45 Body mass index (BMI) 70 or greater, adult
  • The BMI number included in the code description is a weight/height calculation, butshould be coded correctly based on the patient’s age.

The 2019 ICD-10-CM Official Guidelines state that BMI codes cannot be used alone and should be only assigned when the associated diagnosis (such as overweight or obesity) meets the definition of a reportable diagnosis. The provider must provide documentation of a clinical condition such as obesity or overweight to validate the reporting of a code for BMI (www.

Gastrointestinal Symptoms and Disorders linked to Obesity

Overeating is a major cause of obesity and controlling food intake is a major consideration for weight control. Intake of food is associated with major changes in gastric motor function. This is why obesity is associated with many gastrointestinal complications. Nonalcoholic fatty liver disease is directly caused by obesity. Other digestive disorders associated with obesity are:

  • Gastroesophageal reflux disease
  • Barrett’s esophagus
  • Esophageal adenocarcinoma
  • Erosive gastritis
  • Diverticulitis
  • Cancer
  • Gastric cancer
  • Acute pancreatitis
  • Pancreatic cancer
  • Diarrhea
  • Colonic diverticular disease
  • Colon polyps
  • Nonalcoholic fatty liver disease
  • Cirrhosis
  • Hepatocellular carcinoma
  • Gallstones
  • Acute pancreatitis

A report published in 2017 in The Lancet noted that while patients seek medical care for their gastrointestinal problems, their underlying obesity is usually goesunaddressed.

 AGA Obesity Practice Guide calls for a Collaborative Approach

Given the wide range of gastrointestinal symptoms and disorders associated with obesity, gastroenterologists are uniquely positioned to lead a care team for obese patients. In March 2017, the American Gastroenterological Association (AGA) released an “Obesity Practice Guide” to provide gastroenterologists with a comprehensive, multidisciplinary process to lead safe and effective weight management for obese patients.

The AGA guide provides a comprehensive obesity care model for a gastroenterology practice. This includes patient goal setting, readiness assessment, evaluation, and treatment with diet, medication, and bariatric endoscopy and surgery. The various phases in the care plan are as follows:

  • Initial consultation
    • Assessing patient readiness for intervention and managing the overall disease burden
    • Dietary and physical activity assessment
    • Medical assessment of both risk factors for obesity and the complications of disease psychological evaluation.
  • Intervention
    • Dietary adjustments
    • Physical activity and behavioral counseling
    • For select patients – weight loss with pharmacotherapy followed by endoscopic therapy, surgical management, or both (as needed)
  • Follow-up care
    • Weight loss maintenance
    • weight gain–regain prevention

These guidelines emphasize that the success of the obesity care plan depends on a collaborative approach witha multidisciplinary team of dietitians, exercise therapists, nurse educators, psychologists and physicians.

 Obesity spurs Demand for Gastrointestinal (GI) Procedures

Gastroenterologists diagnose and treat a variety of gastrointestinal symptoms and disorders seen in obese individuals and also in the primary treatment of obesity. Medscape reported that the increased prevalence of GI symptoms and disorders in obese individuals has increased the demand for endoscopic and other gastrointestinal (GI) procedures.

GI endoscopy plays a crucial role in the preoperative, intraoperative and importantly, postoperative management of bariatric surgery patients. It is recommended that upper GI system endoscopy is performed in all patients to predict and prevent complications following bariatric surgery. The procedure can identify upper GI symptoms, histal hernias and gastritis.

Bariatric endotherapy is a less invasive, safe and effective endoscopic alternative to bariatric surgery. Medscape lists the uses of bariatric endotherapy in the treatment of obesity as:

  • a primary therapy to induce weight loss and improve obesity-related comorbidities
  • a bridge to surgery in high-risk, severely obese individuals who may not otherwise be candidates forsurgery
  • a metabolic therapy where the main goal is improvement in the metabolic disorders (such as type 2 diabetes, hyperlipidemia, hypertension) with only modest weight loss as a goal

As gastroenterology practices become increasingly involved in the integrated care of obese patients, the support of an experienced medical billing company can prove invaluable to report their services for correct and timely reimbursement.

Peptic Ulcer – Symptoms, Diagnosis, and Assigning the Correct ICD-10 Codes

Peptic Ulcer – Symptoms, Diagnosis, and Assigning the Correct ICD-10 Codes

A common health problem, a peptic ulcer is an open sore that forms when your stomach acids etch away the digestive tract’s protective layer of mucus. This condition usually occurs due to inflammation caused by the bacteria H. pylori, as well as from erosion by stomach acids. According to, up to 10 percent of adults are affected by peptic ulcers at least once in their lifetime. Around 500,000 people develop a peptic ulcer each year in the United States (2017 statistics).

Peptic Ulcer

Typically, peptic ulcers develop inside the lining of the stomach, duodenum, or lower part of the esophagus and the upper portion of your small intestine. A dull or burning pain in the stomach is one of the most common symptoms of this condition, which may occur anywhere from the belly button to the breastbone. Peptic ulcer is a chronic gastric condition that presents different phases of symptoms, which can range from mild to severe. Documentation is critical to ensure appropriate care and accurate reimbursement, and medical coding outsourcing is an ideal option for physicians to streamline their documentation requirements.

Identifying the Causes and Symptoms of Peptic Ulcer

Infection with the bacterium Helicobacter pylori (H. pylori) is one of the common causes of peptic ulcers. Long-term use of aspirin and certain painkillers such as ibuprofen (Advil, Motrin, others), naproxen sodium (Aleve, Anaprox); habits like smoking and alcohol consumption; radiation therapy and stomach cancer can also contribute to this condition.

Generally, small peptic ulcers may not produce any symptoms in the early phases. As mentioned above, the most common symptom is a burning abdominal pain that extends from the navel to the chest. The pain symptoms can range from mild to severe and can be brief or may last for hours. It can become worse when the stomach is empty or right after eating (depending on where it is located) and sometimes become intense during sleep. Some of the other related symptoms include –

  • Feeling of fullness, bloating or belching
  • Nausea and vomiting
  • Heartburn
  • Fatty food intolerance
  • Changes in appetite
  • Bloody or dark stools
  • Unexplained weight loss
  • Trouble breathing
  • Indigestion
  • Difficulty swallowing food
  • Chest pain

Stress and spicy foods do not cause ulcers. However, these can make your symptoms more severe.

Diagnosing and Documenting Peptic Ulcer

Diagnosis of peptic ulcer may initially begin with a detailed evaluation of patient medical history and physical examination. Patients may need to undergo several diagnostic tests such as –

  • Laboratory tests for H. pylori – to determine whether the bacterium H. pylori is present in the body
  • Upper gastrointestinal (GI) X-ray series – A series of X-rays of the upper digestive system is taken to create images of the esophagus, stomach and small intestine. During the procedure, patients need to swallow a thick, white liquid called barium (barium swallow) that coats their digestive tract and makes an ulcer more visible.
  • Upper endoscopy – A long hollow tube, with a lens (endoscope) is passed down the throat and into your esophagus, stomach and small intestine to examine the area for ulcers.

Treatment for this gastric problem will mainly depend on the specific type of ulcer and its underlying causes. Treatment methods may generally focus on killing H. pylori bacterium, (if present). Gastroenterologists may prescribe a combination of medications including –

  • Antibiotics like – Amoxicillin (Amoxil), Metronidazole (Flagyl), Tinidazole (Tindamax) and Tetracycline (Tetracycline HCL)
  • Proton pump inhibitors (PPIs) like – Omeprazole (Prilosec), Lansoprazole (Prevacid), Esomeprazole (Nexium) and Pantoprazole (Protonix)
  • Acid (H-2) blockers like – Ranitidine (Zantac), Famotidine (Pepcid), Cimetidine (Tagamet HB).

Antacids and other prescription medications like sucralfate (Carafate) and misoprostol (Cytotec) may also be prescribed to neutralize stomach acid and protect the lining of your stomach and small intestine.

ICD-10 Codes to Use

Gastroenterologists are reimbursed for the treatments provided to their patients. The diagnosis and other tests offered must be reported on the medical claims using the correct medical codes. Medical billing and coding services provided by reliable companies can help physicians use the correct codes for their medical billing.

Gastroenterology medical coding involves the use of specific ICD-10 codes to document several conditions, including peptic ulcers. The following ICD-10 codes are used to indicate a diagnosis of peptic ulcer for reimbursement purposes –

K27 – Peptic ulcer, site unspecified

  • K27.0 – Acute peptic ulcer, site unspecified, with hemorrhage
  • K27.1 – Acute peptic ulcer, site unspecified, with perforation
  • K27.2 – Acute peptic ulcer, site unspecified, with both hemorrhage and perforation
  • K27.3 – Acute peptic ulcer, site unspecified, without hemorrhage or perforation
  • K27.4 – Chronic or unspecified peptic ulcer, site unspecified, with hemorrhage
  • K27.5 – Chronic or unspecified peptic ulcer, site unspecified, with perforation
  • K27.6 – Chronic or unspecified peptic ulcer, site unspecified, with both hemorrhage and perforation
  • K27.7 – Chronic peptic ulcer, site unspecified, without hemorrhage or perforation
  • K27.9 – Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation

Peptic ulcers, if left untreated can become worse over time and lead to several serious health complications such as internal bleeding, scar tissue and perforation. With proper treatment and consumption of medications, most cases of peptic ulcers heal. In addition, incorporating healthy lifestyle choices such as – quitting smoking and other tobacco use, limiting the frequent use of anti-inflammatory drugs (like ibuprofen, aspirin, and naproxen), and eating a balanced diet will help you prevent developing peptic ulcer in the long run.

Peptic Ulcer – Symptoms, Diagnosis, and Assigning the Correct ICD-10 Codes

How to Accurately Document Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux DiseaseGastroesophageal reflux disease (GERD) is a common digestive disorder that occurs when the stomach acid backs up or refluxes into the esophagus (the tube connecting your mouth and stomach). Also called acid regurgitation, this condition can cause a burning sensation (known as heartburn) in the chest. Documenting this disorder requires correct recording of all the symptoms and treatments provided. Medical coding outsourcing is worth considering as this can help gastroenterologists ensure accurate and timely claim filing and reimbursement.

According to estimates from the American College of Gastroenterology (ACG), about 60 million people in the United States experience acid reflux at least once a month. More than 15 million experience it every day. If left untreated, this gastric disorder can lead to serious complications such as narrowing of the esophagus, esophageal ulcer and precancerous changes to the esophageal structure (known as Barrett’s esophagus).

In most cases, a healthy diet combined with positive lifestyle changes can help reduce the frequency of acid reflux. Treatment methods aim to decrease the amount of reflux or reduce the potential damage caused to the esophaguslining from refluxed materials. GERD can usually be controlled by acid reflux medications such as Antacids, H-2-receptor blockers, Proton pump inhibitors, Histamine antagonists and Foam barriers. However, if medications do not provide the desired effect gastroenterologists may recommend surgical treatments that include – Fundoplication, LINX device and other endoscopic procedures. Gastroenterology medical coding services help physicians report the correct codes that reflect the various treatment services provided to patients in the office or hospital settings.

CPT Codes to Use

  • 43200 – Esophagoscopy, diagnostic
  • 43201 – Esophagoscopy flexible, transoral; with directed submucosal injection(s), any substance
  • 43210 – Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed
  • 43236 – Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance
  • 43241 – Esophagogastroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or catheter
  • 43257 – Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease
  • 43284 – Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty when performed
  • 43289 Unlisted laparoscopy procedure, esophagus
  • 43499 Unlisted procedure, esophagus
  • 43999 Unlisted procedure, stomach

Identifying Causes and Symptoms

Gastroesophageal Reflux Disease

GERD that occurs among people of all age groups is caused by frequent acid reflux. It is more commonly seen in people who are obese or overweight, pregnant women, active or secondhand smokers and people who consume certain medications including – antidepressants, sedatives, calcium channel blockers and antihistamines.

One of the most common symptoms is heartburn or a burning sensation in your chest, usually after eating (which might become worse at night). Some of the other common symptoms include chest pain, regurgitation of food or sour liquid, difficulty swallowing, nausea or vomiting, and a sensation of a lump in your throat.

ICD-10 Diagnostic Codes for GERD

Initial diagnosis will begin with a detailed physical examination and a thorough review of your signs and symptoms. In order to confirm a diagnosis of GERD, or to check for further complications, gastroenterologists may recommend several tests such as – Upper gastrointestinal (GI) endoscope, Esophageal manometry, Ambulatory acid (pH) probe test and Upper GI series X-ray. Incorporating significant lifestyle changes along with over-the-counter medications can help reduce the symptoms. If lifestyle modifications do not considerably improve the symptoms of GERD, or medications do not show the desired effect, a gastroenterologist may recommend surgery as a last resort.

Gastroenterologists who treat GERD rely on reputable medical billing companies to code the condition accurately. The following ICD-10 codes are relevant with regard to gastroesophageal reflux disease –

  • K21 – Gastro-esophageal reflux disease
  • K21.0 – Gastro-esophageal reflux disease with esophagitis
  • K21.9 – Gastro-esophageal reflux disease without esophagitis

Living with gastroesophageal reflux disease (GERD) is difficult. There are several risk factors associated with this condition which may include – obesity, connective tissue disorders (such as scleroderma), bulging of the top of the stomach up into the diaphragm (hiatal hernia), pregnancy and delayed stomach emptying. Healthy lifestyle changes that can reduce the frequency of acid reflux include – quitting the habit of smoking, reducing alcohol consumption, reducing the intake of fatty foods or drinks that trigger reflux, avoiding overeating and losing excess body weight.

Peptic Ulcer – Symptoms, Diagnosis, and Assigning the Correct ICD-10 Codes

Study: Obesity can lead to Severe Liver Disease with Age Progression

Obesity cause Liver DiseaseCoding for liver diseases is a significant aspect in gastroenterology medical billing and coding. Medical News Today recently reported on a new study published in the journal Gut, confirms what earlier research found – that high body mass index (BMI), which indicates obesity, is linked to severe liver disease in later life. When reporting a primary condition with comorbidities, proper physician documentation and use of the right ICD-10 and CPT codes is necessary to provide evidence of severity and medical necessity, improve multidisciplinary care, and ensure appropriate reimbursement.

According to the Centers for Disease Control and Prevention (CDC), more than one-third (35.7 percent) of U.S. adults are obese. The American Liver Foundation reports that up to 25 percent of people in the U.S. are living with NAFLD. In addition to various other medical conditions, obesity in youth can lead to liver diseases such as chronic viral hepatitis B and C, as well as non-alcoholic liver disease.

Researchers from the Centre for Digestive Diseases at the Karolinska University Hospital in Sweden conducted an in-depth study of the link between BMI and liver disease. The research was based on data from 1.2 million Swedish men who were conscripted into the army from 1969 to 1996 as well as from population-based registers charting liver cancer, severe liver disease, and type 2 diabetes. Men who received a diagnosis of alcoholic liver disease during follow-up were not included in the study.

Following the participants from 1 year after conscription, up until the end of 2012, the team analyzed up to 34 million person-years. Their findings are as follows:

  • 5,281 cases of severe liver disease, including 251 cases of liver cancer
  • Compared to men of normal weight, overweight men faced an almost 50 percent increase in risk of liver disease in later life
  • Obese men were more than twice as likely to develop liver disease as they got older
  • Participants with both obesity and type 2 diabetes were more than three times more likely to develop liver problems as they aged

The researchers recommend earlier interventions and additional screening for those at risk, which brings us to diagnostic coding for obesity and liver disease.

When a patient is evaluated for obesity, the physician also evaluates comorbidity conditions that are being treated or that affect the treatment. In this case, liver disease is the comorbidity and therefore the additional diagnoses code should be reported for this condition evaluated that affected the current visit, linked to the appropriate evaluation and management (CPT) code. Diagnosis-related groups (DRGs) should be used to identify related conditions that may affect a patient’s care and which are linked to reimbursement. Likewise, reimbursement for professional services should be reported using appropriate CPT procedure codes.

The primary diagnosis code (primary reason for the visit) is used for the visit, as the first linked diagnosis. Comorbidities affecting the patient’s obesity assessment, evaluation, or treatment that also are evaluated are reported as secondary codes.

In ICD-10-CM, overweight and obesity codes come in category E66. Code E66.3 is used to report overweight. The codes for obesity are: E66.0- due to excess calories; E66.1 if drug-induced; E66.2 with alveolar hypoventilation; E66.8 due to other specified causes, or E66.9, (unspecified).

K70-77 are the diagnostic codes for liver diseases in ICD-10:

  • K70, Alcoholic liver disease
  • K71, Toxic liver disease
  • K72, Hepatic failure, not elsewhere classified
  • K73, Chronic hepatitis, not elsewhere classified
  • K74, Fibrosis and cirrhosis of liver
  • K75, Other inflammatory liver diseases
  • K76, Other diseases of liver
  • K77, Liver disorders in diseases classified elsewhere

Nonalcoholic fatty liver disease refers to a wide spectrum of liver disease, ranging from simple fatty liver (steatosis) to nonalcoholic steatohepatitis, and finally cirrhosis.

K76.0 is the 2017 ICD-10-CM Diagnosis Code for nonalcoholic fatty liver disease (NAFLD).

ICD-10-CM K76.0 is grouped within Diagnostic Related Group(s) (MS-DRG v34.0):

441 Disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with MCC

442 Disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with CC

443 Disorders of liver except malignancy, cirrhosis or alcoholic hepatitis without CC/MCC

Due to ICD-10-CM specificity, most of the diagnosis code sections have multiple codes for particular conditions. There are 115 ICD-10-CM codes grouped within the above 3 MS-DRG groups.

Coding to the highest degree of specificity and to the highest degree of certainty for proper reimbursement is much easier with outsourced medical billing and coding services. Based on physician documentation, expert AAPC-certified codes will link the diagnosis codes to the procedure codes (CPT) on claims, sequence the reporting correctly and code only diagnoses relevant for the current encounter. Such support is vital to ensure consistency with the latest coding conventions and guidelines, prevent claim rejections, and maximize revenue.

Peptic Ulcer – Symptoms, Diagnosis, and Assigning the Correct ICD-10 Codes

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

Gastroenterology Billing ServicesMany 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.