Billing and Diagnosis in Endoscopy: A Comprehensive Guide by Luis S. Marsano, MD, Study notes of Medicine

Download Billing and Diagnosis in Endoscopy: A Comprehensive Guide by Luis S. Marsano, MD and more Study notes Medicine in PDF only on Docsity!

Billing Diagnosis &

Billing in Endoscopy

Luis S. Marsano,MD

Professor of Medicine Division of Gastroenterology, Hepatology and Nutrition University of Louisville and Louisville VAMC

Billing Diagnosis Procedure + E/M on same day Billing in Endoscopy

Billing Diagnosis

Billing Diagnosis

Outpatient Visits

• The reason that prompted the visit (sign/symptom/diagnosis)

  Hospital care

• The final diagnosis; – If final diagnosis is not known, then use the reason of the admission (sign/symptom) - Diagnostic study/surgery

Requires valid indication/reason (necessity)

The final diagnosis;

• 3. If exam is normal, then bill under: Sign or symptom/reason that prompted the study/surgery.

E&M Service in the same

day of a Procedure

Modifier - 25

Significant E&M on “Global Procedure Period”: MODIFIER 25

E&M in day of procedure is for “significant, separately identifiable E&M beyond the pre-operative and post-operative work of theprocedure” - If billing “inpatient dialysis code” (90935, 90337, 90945, 90947) you must document that “service was unrelated and could not beperformed during dialysis procedure”

MODIFIER - 25

E&M visit on the same day of endoscopy orminor surgery (e.g.: cardiac cath) is payable if“significant, and separately identifiable”(separate notes are needed). - Example: Patient admitted for “Unstable angina”;next day has normal cardiac cath; patient isdischarged in view of cath findings: Bill for “cardiac cath” and “E&M discharge service”on same day (with 25- modifier for E&M).

BILLING IN ENDOSCOPY

Medicare Conversion Factor

38.08 (peak value)

34.02 (24.84 was proposed)

Billing in Endoscopy

Pre-approval required : - Obtain pre-approval for procedure giving clinical

information that clearly explains why is needed(ASGE guidelines).

• Be sure procedure is done within the approved

period.

No pre-approval required : - Be sure that the indication of the procedure is

consistent with ASGE guidelines and

• Indication is in the list of “IDC-9 which support

Medical Necessity” from Medicare Policy.

If the Indication/Medical Necessity is not valid, you will not be paid (Is considered Fraud )

Endoscopy Billing

All normal diagnostic or screening exams are billed under:

Primary ICD-9 (until Sept 31) or 10: The indicationof the procedure.

• Copayments waived for normal

“screening

procedures”

All exams with abnormal findings related to the “indication” or which require intervention (eg. Bx, removal, dilat.) are billed under:

Primary ICD-9: Final diagnosis

Secondary ICD-9: The indication of the procedure

Endoscopy Billing

All exams with abnormal “incidental” findings not related to the “Indication /Medical Necessity” are billed under:

Primary IDC-9 or 10: The indication of theprocedure.

Secondary ICD-9 or 10: The incidental finding (s)

All SCREENING exams with normal or only incidental findings , should be billed under:

Primary ICD-9: Screening V-code

Endoscopy Billing Extent of Exam – Colon Family

-^ YOU SHOULD ALWAYS DOCUMENT THE MOST DISTANT POINT REACHED. - Colonoscopy : (45378-45387) Base RVU: F= 6.48; NF= 11. - if the splenic flexure is passed - Screening Colonoscopy: (G0105- high risk & G0121-average risk) - if the splenic flexure is passed - Sigmoidoscopy : (45330-45345) Base RVU: F= 1.90; NF= 4. - beyond the rectum and up to the splenic flexure - Screening Sigmoidoscopy: (G0104) - beyond the rectum and up to the splenic flexure - Proctosigmoidoscopy : (45300-45305) - Rectum + sigmoid only - Anoscopy : (46600-46606) - anus only - Colonoscopy via stoma (44388-44397) Base RVU: F= 4.97; NF=10.

Modifier when “Screening” Service is converted to Diagnostic/Therapeutic Service •^

Examples:

• Screening Colonoscopy (GO105, GO121) is converted to Diagnostic due to biopsy, or Therapeutic due to polypectomy. - Screening Flex Sigm (GO104)

Medicare: Modifier “PT”

• Screening Colonoscopy + Bx or Polypectomy: GO105-PT;

GO121-PT

• Screening Flex Sigm + Bx: GO104-PT – Waives deductible BUT co-pay applies.

Commercial: Modifier 33

• Screening Colonoscopy + Bx or polypectomy: 45385-33 – Screening Flex Sigm + Bx: 45330-