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

An in-depth analysis of billing diagnosis and procedures in endoscopy. It covers various aspects such as federal regulations, ICD-9 codes, CPT codes, and billing for diagnostic studies and surgeries. The document also explains the concept of E&M services and modifier 25, as well as the calculation of Total RVU and Medicare Conversion Factor. It is essential for medical students, residents, and healthcare professionals involved in endoscopy billing and coding.

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Billing Diagnosis &
Billing in Endoscopy
Luis S. Marsano,MD
Professor of Medicine
Division of Gastroenterology, Hepatology and Nutrition
University of Louisville and Louisville VAMC
2014
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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;

    1. 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-