Billing in Gastroenterology: A Complete Guide

Gastroenterology Billing Overview
  • Avatar photo Victor Bala
  • Jul 11 2024
  • Reading Time: 13 minutes.

Any gastroenterologist knows that GI services are hard to bill. To receive payment for the delivery of your services, you have to comply with a large number of codes and regulations. This blog post reviews key principles for billing GI services. We discuss everything from CPT codes to ICD-10 codes. We will also provide tips on how to earn higher pay for your services. Therefore, if you are ever interested in a how-to-bill GI series with much-needed guidance about billing for your gastroenterology services,.

Gastroenterology Definition

What is Gastroenterology medical billing? It is a segment of medicine that deals with the diagnosis and treatment of diseases impacting the stomach, esophagus, large intestine, small intestine, gallbladder, biliary tree, and pancreas. Gastroenterology has a wide range of diseases, from common ones like diarrhea and heartburn to serious ones (e.g., colitis and cancer). They also provide colon cancer prevention and screening. Gastroenterologists are trained in endoscopy, a procedure that requires the use of tubes or scopes to see inside body cavities. Gastroenterologists use endoscopy to treat and diagnose conditions like ulcers, tumors, or blockages. Naturally, as medical practices evolve with time, gastroenterology is one of the specialties that tend to experience sudden growth and changing procedures.

Gastroenterology Medical Billing Services

Medical billing is the process of submitting and following up on claims to health insurance companies in order to receive payment for services rendered by a healthcare provider.

Coding: Conversion from billing to numerical codes related to medical diagnoses and treatments. The importance of medical billing and coding in gastroenterology is that they help clinicians get reimbursed for the services offered to a patient.

Endoscopies, colonoscopies, and upper GI endoscopies are some of the procedures performed by gastroenterologists. All of these standardized procedures can be utilized with a specific code that represents the medical procedure used to prescribe drugs or medications under insurance, so long as the mentioned process is completed successfully. To process claims properly, medical billers and coders need to be knowledgeable about diagnosis codes in addition to procedure codes. Many diagnostic codes can be used by gastroenterologists (e.g., GERD, abdominal pain, and celiac disease). When it comes to medical billing and coding in gastroenterology, the range of services can tend to make things challenging. Nevertheless, gastroenterologists can make sure that their claims are submitted accurately and promptly by working with trained medical billers and coders.

Outsourced Gastroenterology Billing Workflow

When a patient receives medical care from a provider, such as in the office of a doctor or outpatient clinic (or hospital), the process starts. The provider will then create a claim; essentially, this is the same as an invoice in any business except that it lays out what services were provided and how much each one of them costs. This sends the medical claim to their insurance for payment. The insurance carrier also has to process your medical claim and determine if it adheres to its provisions for you to receive payment. For each medical claim that is approved, the insurance company will pay for a portion of or the full cost of whatever service is provided by the provider. Medical billing is a complicated process, and providers have to understand it so that they will receive payment for their services. Medicine is complicated, and gastroenterologists should work with experienced medical billers to ensure their claims are correct.

Top Professional Outsource Healthcare Billing and Coding Services

Outsourcing medical billing can be an effective way for healthcare providers to manage their revenue cycle efficiently. One of the primary benefits of outsourcing is the ability to leverage the expertise of specialized billing companies that are well-versed in the nuances of medical billing and coding. This is particularly beneficial for gastroenterologists, who often deal with complex procedures and a wide range of diagnostic and procedural codes.

Velan HCS is one such company that provides comprehensive medical billing, credentialing, and accounts receivable management services. They specialize in ensuring that claims are accurate and compliant with the latest healthcare regulations, which can significantly reduce the likelihood of denials and improve overall revenue.

Outsourcing can also save time and reduce costs. Medical practices do not need to invest in hiring and training staff or maintaining the latest billing software. Instead, they can focus on providing quality patient care while the billing company handles the administrative burden. However, it is important to choose a reliable and experienced billing partner to avoid potential issues related to control and data security.

Coding and Billing in Health Care: Best Practices for Gastroenterology

Medical billing for gastroenterology is the process of submitting and following up on claims with health insurance companies to receive payment for services such as office visits, colonoscopy, endoscopic retrograde cholangiography (ERCP), and endoscopic ultrasound (EUS). A medical coder takes the text in a patient chart and applies codes to diagnoses and services per an established classification system so claims are accurately processed by payors (and you get paid). Gastroenterologists are required to familiarize themselves with the coding system used to correctly code for the medical services rendered. Another step for pathologists (and other providers) is to be knowledgeable about the criteria established by various insurance companies and third-party payers to avoid denial of reimbursement. Following coding guidelines will help ensure your medical billing is correct and payouts come through on time for gastroenterology.

Billing and Coding for Upper Gastrointestinal Endoscopy

The following ICD-10-CM codes support medical necessity and offer coverage for CPT codes: 43200, 43201, 43202, 43204, 43205, 43206, 43212, 43215, 43216, 43217, 43220, 43226, 43227, 43229, 43231, 43232, 43235, 43236, 43237, 43238, 43239, 43240, 43241, 43242, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43252, 43255, 43257, 43259, 43260, 43261, 43262, 43263, 43264, 43265, 43266, 43270, 43274, 43275, 43276, 43277, and 43278.

In certain cases, a physician may need to state that a procedure or service was unique or independent of other services, and CPT® modifier 59 may be appropriate depending on the circumstances. CPT® Modifier 59 is used to identify procedures or services that are not generally reported simultaneously. This includes the following procedures or services that are not commonly encountered or performed on the same day by the same doctor:

  • A different session or patient interaction
  • A different procedure or surgery
  • A different site or organ system
  • A separate incision/excision
  • A separate lesion
  • A separate injury (or area of injury in serious injuries)

When an existing established modifier is acceptable, it should be used instead of CPT® modifier 59. CPT® Modifier 59 is an important National Correct Coding Initiative (NCCI)-linked modification that is frequently misused. It should only be used when no other descriptive modifier is available or when it best describes the situation.

For example, the 59 modifiers can be used with the codes shown below:

  • 45380 — Flexible colonoscopy with biopsy, single or multiple
  • 45385 — Flexible colonoscopy with removal of tumor(s), polyp(s), or other lesion(s) using the snare technique
  • 45386 — Flexible colonoscopy with trans-endoscopic balloon dilation
  • 45387 — Flexible colonoscopy with removal of tumor(s), polyp(s), or other lesion(s) using hot biopsy forceps or bipolar cautery

Proper coding and modifier use are crucial for accurate billing and avoiding claim denials. Gastroenterologists must stay updated on coding guidelines and payer policies to ensure compliance and maximize reimbursement.

ICD-10 and CPT Codes in Gastroenterology

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the Current Procedural Terminology (CPT) codes are essential tools for gastroenterology billing and coding. These codes standardize the reporting of diseases and procedures, facilitating accurate billing and insurance claims processing.

ICD-10-CM codes are used to describe the patient’s diagnosis, while CPT codes are used to describe the medical procedures and services provided. For example, a colonoscopy might be coded with CPT 45378, and a diagnosis of irritable bowel syndrome might be coded with ICD-10-CM K58.0.

To ensure proper reimbursement, gastroenterologists must use the most specific and accurate codes available. This often involves keeping up with annual updates to the coding systems and payer guidelines.

Challenges in Gastroenterology Billing

Billing for gastroenterology services comes with a unique set of challenges. These include dealing with a wide variety of procedures, each with its specific codes and guidelines, as well as managing the documentation and coding for complex cases that may involve multiple procedures or comorbid conditions.

Another significant challenge is staying compliant with constantly changing regulations and payer policies. Failing to adhere to these can result in claim denials, payment delays, or even audits and penalties.

To navigate these challenges, many gastroenterologists turn to specialized medical billing services. These services can provide the expertise and resources needed to manage billing effectively, ensuring accurate claims submission and timely reimbursement.

Top Professional Outsource Healthcare Billing and Coding Services

Outsourcing medical billing can be an effective way for healthcare providers to manage their revenue cycle efficiently. One of the primary benefits of outsourcing is the ability to leverage the expertise of specialized billing companies that are well-versed in the nuances of medical billing and coding. This is particularly beneficial for gastroenterologists, who often deal with complex procedures and a wide range of diagnostic and procedural codes.

Velan HCS is one such company that provides comprehensive medical billing, credentialing, and accounts receivable management services. They specialize in ensuring that claims are accurate and compliant with the latest healthcare regulations, which can significantly reduce the likelihood of denials and improve overall revenue.

Outsourcing can also save time and reduce costs. Medical practices do not need to invest in hiring and training staff or maintaining the latest billing software. Instead, they can focus on providing quality patient care while the billing company handles the administrative burden. However, it is important to choose a reliable and experienced billing partner to avoid potential issues related to control and data security.

Another reputable outsourcing option is Billings Clinic Gastroenterology, which offers end-to-end revenue cycle management services. MBC’s team of certified coders and billing specialists ensures that claims are processed accurately and efficiently, helping healthcare providers maximize their revenue.

Additionally, Accurate Billing provides tailored billing solutions for gastroenterology practices. Their services include claim submission, denial management, and patient billing, all designed to streamline the revenue cycle and reduce administrative burdens on healthcare providers.

When choosing a medical billing service, it’s essential to consider factors such as the company’s experience in gastroenterology billing services, its compliance with industry standards, and its track record of success. By partnering with a top professional outsourcing service, gastroenterologists can ensure that their billing processes are efficient, accurate, and compliant, ultimately leading to better financial outcomes and more time to focus on patient care.

Conclusion

Effective billing in gastroenterology requires a thorough understanding of coding systems, payer policies, and the specific challenges associated with GI procedures. By staying informed and leveraging the expertise of professional billing services, gastroenterologists can optimize their revenue cycle, reduce claim denials, and ensure timely reimbursement for their services.

Whether you choose to manage billing in-house or outsource to a specialized company, the key is to maintain accuracy, compliance, and efficiency in your billing processes. This will not only improve your practice’s financial health but also allow you to focus more on delivering high-quality care to your patients.

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Victor Bala

Medical & coding

About the Author:

Victor has over a decade of experience in delivering revenue cycle management services to the US healthcare providers. He has a proven track record of accelerating revenue collection by streamlining the billing, coding and AR processes. His team at Velan has been delivering revenue cycle management cycle, appointment scheduling, pre-authorization and credentialing services to physicians, group practices, and hospitals.

He can be reached at [email protected]

Considering the complexities of healthcare billing in the USA, why choose Velan HCS for your billing services?