• Colonoscopy 45378, 45380, 45385, 45388, 45384
• Esophagogastroduodenoscopy (EGD) 43235, 43239, 43250
• Endoscopic Retrograde Cholangiopancreatography (ERCP) 43260, 43261, 43265
• Endoscopic Ultrasound (EUS) 43231, 43237
• Capsule Endoscopy 91110
• Sigmoidoscopy and Proctosigmoidoscopy 45330, 45331, 45333

The Modifier is additional information regarding the specific aspect of a medical procedure or service. It is a two-character code added to Current Procedural Terminology (CPT) or Health Common Procedure Coding System (HCPCS) to reflect the specific circumstance of the procedure performed. Incorrect use of modifiers may lead to claim denials and lower reimbursement rates. Some of the key modifiers used in gastroenterology billing are mentioned below.

• Modifier-22 for Increased Procedural Services
• Modifier-51 for Multiple Procedures
• Modifier-52 for Reduced Services
• Modifier-53 for Discontinued Procedure
• Modifier-59 for Distinct Procedural Service
• Modifier-99 for Multiple Modifiers

• ICD-10 codes inform about diagnostic information, while CPT codes convey procedural or service-related information.
• ICD-10 codes are alphanumeric (e.g., G11.0), whereas CPT codes are numeric (e.g., 45378).
• ICD-10 codes are on the patient’s condition, disease, or diagnosis, while CPT codes focus on the services provided by the healthcare provider
• ICD-10 codes support medical necessity and justify the need for specific procedures. CPT codes are used to identify the specific procedures or services performed
• ICD-10 codes are linked to CPT codes in medical billing to show the relationship between the patient’s diagnosis and the procedures or services rendered.

• Ensure that the healthcare practice is enrolled as a Medicare provider and that all gastroenterologists are properly credentialed with Medicare.
• Verify the patient’s Medicare eligibility and coverage to avoid claim denials
• Correct usage of Medicare-specific modifiers when applicable
• Comply with Medicare billing rules and regulations to avoid audits and penalties.

• Ensure that the healthcare practice is enrolled as a Medicaid provider in the state’s Medicaid program.
• Determine if prior authorization is required for specific gastroenterology procedures or services and obtain it as necessary.
• Stay in compliance with Medicaid guidelines of the state for Billing codes, modifiers, and any specific requirements
• Ensure claims are submitted within the specified timeframes.
• Stay updated on Medicaid policies through provider training sessions

Evaluation and Management (E/M) service is based on several factors, commonly referred to as “Three Key Components” and “Medical Decision Making. To determine the appropriate E/M level for office visits, the following procedures must be put in place.

Three Key Components

Evaluate Patient’s history by documenting chief complaint, history of present illness (HPI), review of systems (ROS), and past medical and social history (PFSH). Perform physical examinations relevant to patients’ complaints. The extent of the examination should be commensurate with the complexity of each case

Medical Decision Making (MDM)

Medical Decision-Making process includes

• The number and complexity of the patient’s problems addressed during the visit.
• The amount and complexity of data reviewed (e.g., test results, imaging).
• The risk of complications, morbidity, or mortality is associated with the patient’s condition.

Selecting the Appropriate E/M Level

The E/M levels are typically categorized into five levels, level 1 being the lowest complexity to level 5 being the highest complexity.

• Avoid any payments or agreements that are prohibited under the AKS.
• Comply with Stark Law, which prohibits referrals for certain designated health services, including certain gastroenterology procedures.
• Adhere to CPT and ICD-10 guidelines.
• Support the codes billed with relevant documents.
• Follow specific regulations and guidelines when billing for services provided to Medicare and Medicaid beneficiaries
• Ensure patient information is protected and that they comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations.
• Implement NCCI edits to ensure that procedures are correctly bundled or unbundled based on CMS guidelines
• Use modifiers to convey information for specific circumstances