Insurance reimbursements are core to any practice’s successful day-to-day operations and Gastroenterology practices are no exception. However, Gastroenterologists are not trained for this business side of medicine i.e., medical billing and coding. They come out of training with the knowledge to treat patients but with little or no knowledge of how to get reimbursed for their services. Plus, they want to spend most of their time in patient care rather than in such administrative activities.

1. 4 Key Points in Gastroenterology Billing To Get Reimbursed

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Email us at: kbradley@legionhealthcaresolutions.com
4 Key Points in Gastroenterology Billing To Get Reimbursed
Reimbursement Challenges for Gastroenterologists
Insurance reimbursements are core to any practice’s successful day-to-day operations and Gastroenterology practices
are no exception. However, Gastroenterologists are not trained for this business side of medicine i.e., medical billing and
coding. They come out of training with the knowledge to treat patients but with little or no knowledge of how to get
reimbursed for their services. Plus, they want to spend most of their time in patient care rather than in such
administrative activities. In this article, we focussed on 4 key points in Gastroenterology billing that will help your
practice to get reimbursed, timely and accurately. Before discussing these key points, let’s understand the basics of
insurance reimbursements for any healthcare practice.
Insurance Reimbursement Basics
The insurance reimbursements are majorly based upon Relative Value Units (RVUs) assigned to every service provided.
Any physician services depend upon three factors i.e., physician work value, malpractice cost, and practice expense.
These three factors are added together and multiplied by a conversion factor assigned by the Centers for Medicare &
Medicaid Services (CMS) which creates the national physician fee schedule. Each Medicare carrier has localities, and
there is another percentage that is multiplied based on geographic location, which will finalize the approved amount for
each service. While third-party/ commercial insurance carriers most commonly base their contracts on the Medicare Fee
Schedule. Know that even though they have Medicare rates as a base, each practice and insurance carrier relationship is
different. Medicare and commercial insurance carriers will often have local coverage determinations (LCDs) for
procedures and testing that include indications and restrictions along with approved diagnosis codes.

3. Call us at: 727-475-1834
Email us at: kbradley@legionhealthcaresolutions.com
4 Key Points in Gastroenterology Billing To Get Reimbursed
4 Key Points in Gastroenterology Billing To Get Reimbursed
1. Evaluation and Management (E&M) Services
As the name evaluation and management indicates, these codes are applicable to visits and services that involve
evaluating and managing patients. Examples of E/M services include office visits, hospital visits, home services, and
preventive medicine services. Medicare, Medicaid, and other third-party insurance carriers accept E/M codes on claims
that physicians and other qualified healthcare professionals submit to request reimbursement for their professional
services. Small E/M coding mistakes can cause major compliance or payment issues if the errors are repeated on a
regular basis. Insurance carriers often see that visits are chosen by ‘guessing’ the level, which leads to choosing either a
lower or higher level of E/M service than what was actually provided.
Sometimes Gastroenterologists are instructed that E/M services are not that important since procedures are the major
source of revenue for the practice. However, Gastroenterology practices are visit-driven, and the initial visits are often
worth more RVUs than some procedures. Evaluation and Management (E&M) services are also important as they form
the base for the medical necessity of any additional procedures and diagnostic services required in order for the
successful treatment of the patient. To prove medical necessity and reimbursement for these services, those involved in
the coding process (including Gastroenterologists) need to stay up to date on E/M coding rules.

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Email us at: kbradley@legionhealthcaresolutions.com
4 Key Points in Gastroenterology Billing To Get Reimbursed
2. Endoscopy and Procedural Billing
Gastroenterologists will often use multiple techniques when treating different areas within the gastrointestinal tract. All
must be documented properly including the location of lesions/abnormalities, method of treatment/removal, and the
reason(s)/indication(s) for those procedures. There may be different instruments used in the colon (for example, snare
in the sigmoid colon or biopsy forceps in the transverse colon). These may be separately reported with an appropriate
modifier to indicate that these services were performed for different lesions/abnormalities. Gastroenterologists are also
responsible for accurate and specific documentation and guiding billing staff for claim submission. They along with the
whole coding staff need to have an open line of communication to make sure that everything is submitted appropriately
according to insurance carriers’ reimbursement policies.
To succeed in today’s billing environment the gastroenterologist should surround their practice with staff, resources, and
education. Experienced skilled staff, preferably a Gastroenterology certified professional coder should be employed.
These certified coders can bring advanced coding skills to your Gastroenterology practice, which allows increased
proficiency. Provide the necessary resources for staff. The latest coding material is crucial to the financial success of the
practice. ICD-10 and Correct Coding Guide are the bare basics of the resource material available to staff. Maintaining a
library of resource material (i.e., Medicare bulletins, and managed care newsletters) helps your billing staff with the
necessary tools to carry out their duties. It is imperative that your coding team attends all Medicare-sponsored
workshops in addition to gastroenterology-specific coding seminars.

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Email us at: kbradley@legionhealthcaresolutions.com
4 Key Points in Gastroenterology Billing To Get Reimbursed
3. Diagnostic Studies
Medical necessity/indication for the testing must be documented in order to submit charges for diagnostic studies. The
terms ‘rule out’ and ‘suspect’ don’t completely give coders the reason why a physician suspects the patient might have a
condition. Usually, abnormal lab tests, signs, and symptoms will often warrant the need for further investigation, and
these are the most crucial indications for testing. Not only is this important for diagnostic studies but also for
procedures. Make sure that the interpretation of the test results is clear along with a plan/recommendation(s).
Medical necessity for testing must be documented in order to submit charges for diagnostic studies. Your notes with
remarks like ‘rule out’ or ‘suspect’ don’t completely give coders the reason why you suspect the patient might have a
condition. Normally, abnormal lab tests, signs, and symptoms might often warrant the need for further investigation.
Make sure that the interpretation of the test results is clear along with a plan or recommendation for the next steps.
4. Diagnosis Codes
Assignment of procedure codes per the International Classification of Diseases, 10th revision, Clinical Modification (ICD-
10-CM) is the next and most important step after a visit, diagnostic study, and/or procedure. It’s not easy to choose
accurate diagnosis codes as there are nearly 72 thousand ICD-10-CM codes to choose from. Diagnosis codes support
medical necessity for the services provided, and the correct diagnosis code is vital to the successful submission and
payment of a claim. Comorbidities that impact the provider’s decision-making should also be added as additional
diagnoses to support the higher level of decision-making.

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Email us at: kbradley@legionhealthcaresolutions.com
4 Key Points in Gastroenterology Billing To Get Reimbursed
Up to 12 diagnosis codes can be assigned to any type of service provided. If specific information is not in the
documentation for your staff to access, payers will often deny certain lab and radiology studies, as well as some
procedures.
Getting reimbursed for Gastroenterology billing requires attention to detail and communication with your entire billing
team, including all providers. Make sure that your team is educated on current Gastroenterology billing and coding
guidelines along with various payer reimbursement policies. If you are having issues forming a billing team, contact us
for your Gastroenterology billing and coding requirements. Legion Healthcare Solutions is a leading medical billing
company providing complete Gastroenterology billing and coding services. Our team of experts ensures that you will
receive timely and accurate insurance reimbursements for every insurance carrier. To know more about our
Gastroenterology billing and coding services, contact us at 727-475-1834 or email us at
info@legionhealthcaresoltions.com

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