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Gastroenterology Workshop: Part 2 Compliance Issues & Endoscopy Billing. McVey & Associates, Inc Sponsored by: NASPGHAN October 21 & 22 Buena Vista Palace Resort & SPA Orlando, FL. Presenter:. Kathleen A. Mueller, RN, CPC, CCS-P, CCC, CMSCS 204 E Locust St Lenzburg, IL 62255

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Gastroenterology Workshop: Part 2 Compliance Issues & Endoscopy Billing

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gastroenterology workshop part 2 compliance issues endoscopy billing

Gastroenterology Workshop:Part 2Compliance Issues & Endoscopy Billing

McVey & Associates, Inc

Sponsored by:


October 21 & 22

Buena Vista Palace Resort & SPA

Orlando, FL

  • Kathleen A. Mueller, RN, CPC, CCS-P, CCC, CMSCS
  • 204 E Locust St
  • Lenzburg, IL 62255
  • Fax: (618) 475-3622
  • E-mail:
scenario 1
Scenario 1

Dr. Smith is a patient in our practice.

Because he refers many of his patients to our practice, we never bill Dr. Smith, his staff, and other members of his family anything over what insurance pays for their services.

professional courtesy stark ii
Professional Courtesy (STARK II)

Professional courtesy is defined as "the

provision of free or discounted health care items

or services to a physician or his or her immediate

family members or office staff". Besides the

prohibition to Medicare patients, the following

rules apply to all other patients:

professional courtesy stark ii5
Professional Courtesy (STARK II)
  • Phase II effective date July 26, 2004
  • Must be offered to all physicians on the practice’s staff or in the local community without regard to volume or value of referrals
  • May include only those services regularly offered by the practice
professional courtesy stark ii6
Professional Courtesy (STARK II)
  • Must be a policy written and approved by top practice management
  • Cannot be offered for copay waivers unless the insurance company paying the bill is informed in writing
  • Does not violate anti-kickback laws or claims submission rules and regulations.

Scenario 2

A patient presents to a hospital-based clinic complaining of blood emanating from his rectum and severe abdominal pain. As instructed, the staff hands the patient a clipboard with a patient registration form and asks the patient to complete the form which includes the patient’s insurance information. Only after the patient completes the form is the patient seen by the physician.


Any patient that presents to a hospital-based clinic in a potentially emergency situation must be given a screening examination before he/she is questioned regarding their health insurance.


Scenario 3

Though our practice is very careful when it comes to billing Medicare or Medicaid for all applicable copays, coinsurance and deductibles, we do offer professional courtesy in the form of “bill insurance only” to commercial payors for services provided to the medical community.

false claims act
False Claims Act

It is a violation of federal law to submit a claim for payment for a service when the amount billed does not represent the amount that is actually charged.


Anti-kickback and False Claims apply to all “health care benefit programs”, federal or private.


Scenario 4

The family of our patient, who was recently admitted to a nursing facility, asked if we could continue to see the patient in the nursing facility. Since we are not accustomed to seeing patients outside our office or hospital, and since the Medicare payment that we would receive would not be sufficient compensation for the travel time back and forth to the nursing facility, we asked the family to pay a nominal amount above the Medicare allowed amount to cover our additional costs.

medicare regulations
Medicare Regulations

Unless the physician “opts out” of the Medicare program, he/she can not charge more than the Medicare allowed, for participating providers, or the limiting charge, for non-participating providers, even if the patient is willing to pay more.


Scenario 5

One of the drug reps that comes to visit our office with samples of her products, often will provide our staff with, pens, pads, and other small items. Once a month she brings lunch for the physicians and staff, often from a gourmet restaurant. For Christmas, she brings a pair of theater tickets for each of us.

anti kickback

Anything over $300 per year in total value is suspect.

scenario 6
Scenario 6

The Practice has hired a nurse to manage our inflammatory bowel clinic. On occasion the physician is not in the office during the clinic hours. The Practice bills a 99211 for the nurse visit under the physician’s name.

incident to
Incident To...

The “Incident to” provision of Medicare allows a physician to bill for services provided by someone else assuming the following criteria are met:

  • The person providing the service is an employee of the group.
  • The person providing the service is directly supervised by the billing physician.
  • The service is part of a course of treatment prescribed by the physician.
scenario 7
Scenario 7

A practice brings on a new associate. It takes several months before the associate receives all her insurance provider numbers. In the meantime, services provided by the new associate are billed using the provider numbers of another physician in the group.

false claims act19
False Claims Act

Whether Medicare or any other private insurance carrier, a claim identifying the provider as one person, when in fact the person providing the service was someone else, is considered a false claim.

scenario 8
Scenario 8

A patient calls the office wanting to be scheduled for a screening colonoscopy. The physicians in this practice feel strongly that the patient should be seen and examined prior to scheduling the procedure. The patient is asked for the name of her primary care physician. The visit preceding the colonoscopy is billed as a Consultation.

false claims act21
False Claims Act

A Consultation in billing terminology requires a request from another physician for an evaluation of a specific problem. As the request was for a screening colonoscopy only, the visit can not be billed as a Consultation and the claim is a False Claim.

scenario 9
Scenario 9

A patient received a procedure during which biopsies were taken and sent to the laboratory. The results come back negative. The nurse calls the patient at home and leaves the following message on the answering machine: “Mrs. Jones, this is Dr. Smith’s office. Your tests came back negative. Everything is normal. Call us to schedule an appointment for 6 months”.


HIPAA precludes the practice from leaving patient identifiable information on a machine that is not secure. This practice also violates state confidentiality laws.

scenario 10
Scenario 10

An attending physician in a teaching hospital supervises a resident clinic. The attending only sees the patient when requested by the resident. The attending reviews and signs all the charts and bills for all the services provided by the residents.

physicians at teaching hospitals guidelines
Physicians at Teaching Hospitals Guidelines

For the service to be billable by the attending physician, he/she would have to see the patient and document his/her participation in each component of the service: History, Examination, and Medical Decision Making.

scenario 11
Scenario 11

A practice receives a letter from Medicare requesting the medical record documentation for 10 services. Since the documentation was minimal or non-existent, the physicians destroyed the original documentation and dictated new documentation for the 10 services which were sent to Medicare.

obstruction of justice
Obstruction of Justice

It is prohibited for a physician to destroy or alter medical record documentation without identifying the change and the date it was made. Doing so is a felony.

scenario 12
Scenario 12

The practice decided to withdraw from participation in a major managed care plan because they discovered that the out-of-network payment is considerably higher than the in-network payment. To minimize the out-of-pocket expenses of the patients, the practice waives the co-insurance.

false claims act29
False Claims Act

The amount billed to the insurance company must reflect the amount that the practice intends to collect, including the patient’s responsibility. If the practice does not intend to pursue the patient for their responsibility, the insurance company can refuse to pay the practice for the service.

scenario 13
Scenario 13

Because the insurance company does not pay for routine physical examinations, the practice gives the patient a statement indicating that the patient had symptoms, when no significant symptoms actually exist.

false claims act31
False Claims Act

Changing the diagnosis to make a non-covered service into a covered service is considered fraud even if the practice does not stand to benefit.

scenario 14
Scenario 14

Because the physician does not understand the billing and coding process, he relies on the biller to code the services. The biller uses the same level of service for all E/M services, resulting in upcoding for some and undercoding for others.

false claims act33
False Claims Act

The physician has responsibility for the accuracy all services billed under his signature.


Scenario 18

Our office is on the campus of the hospital. We pay a token rent and the hospital provides the support staff. We bill “place of service”, “office”.

anti kickback stark ii false claims
Anti-kickback, Stark II, False Claims

1. The Hospital is providing something of value (reduced rent and staff) in exchange for referrals.

2. The Physicians are referring to hospital (designated health entity) where they have a financial interest (subsidized rent and staff).

3. The physicians are Billing “place of service”, “office”, when the practice does not incur all the overhead expenses.

compliance check list
Compliance Check List
    • Sit in the waiting room to see if you can overhear any conversation with or about patients.
    • Stand at the front desk and see if you can read the computer screen or view any patient information on the desk.
    • Walk through the office to see if any patient- information is left in public places.
compliance check list37
Compliance Check List
  • HIPAA Continued
    • Make sure exam room and consultation room doors are closed when the physician of other staff person is talking to a patient.
    • Instruct your staff never to leave test results, instructions, or other information that identify a problem or procedure on an answering machine or with anyone other than the patient unless the patient specifically agrees in writing.
compliance check list38
Compliance Check List
  • Coding and Billing
    • Unless you are a Medicare non-participating provider, you should have one fee schedule for all patients.
    • Design a written discount policy for indigent patients and follow the policy consistently.
    • Eliminate professional courtesy.
compliance check list39
Compliance Check List
  • Coding and Billing Continued
    • Bill only those services documented in the medical record.
    • Schedule annual training sessions for physicians and staff.
    • Train new physicians as soon as they start.
    • Code all services accurately.
    • Do not send duplicate claims unless the insurer indicates that the claim was lost.
compliance check list40
Compliance Check List
  • Coding and Billing Continued
    • Make sure all information on the claim form is correct, including the name of the provider, the procedure and diagnosis codes.
    • Code the primary diagnosis with the reason for that specific encounter.
    • Select the level of service that is medically appropriate for the patient’s condition as documented in the medical record.
compliance check list41
Compliance Check List
  • Coding and Billing Continued
    • Select the correct category of service as documented in the medical record.
    • Vary the level of service according to the patient’s problem.
    • Use templates to document all of the elements of a visit.
compliance check list42
Compliance Check List
  • Incident to…
    • Get your mid-level providers their own provider numbers.
    • New Patient Visits and Consultations should be billed under the person who provided the service.
    • Assure that there is a physician in the office whenever a service is provided by a nurse, medical assistant, or technician.
    • Bill NPP services under a physician who is in the office and only for established patient visits.
compliance check list43
Compliance Check List
  • Teaching Physicians
    • Bill attending services if performed entirely by the attending or appropriately documented when a resident or fellow participates in the service.
    • Never bill for a procedure performed by a resident or fellow if the attending did not meet the requirements.
teaching physician documentation requirements
Teaching Physician Documentation Requirements

Teaching Physician must personally document:

  • She/he performed the service, or were physically present during the key or critical portions of the service when performed by the resident or fellow
  • His/her participation in the management of the patient
  • Reference the resident’s note
teaching physician documentation requirements45
Teaching Physician Documentation Requirements

Examples of Unacceptable Documentation:

  • “Agree with above”
  • “Rounded, reviewed and agree”
  • “Discussed with resident”
  • “Seen and agree”
  • “Patient seen and evaluated”
  • “A legible countersignature alone”
teaching physician documentation requirements46
Teaching Physician Documentation Requirements

Examples of Acceptable Documentation:

  • “I personally saw the patient with the resident and agree with the resident’s findings and plan.”
  • “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s notes.”
teaching physician documentation requirements47
Teaching Physician Documentation Requirements

Examples of Acceptable Documentation:

  • “I personally examined and evaluated the patient, reviewed the residents notes and made any appropriate corrections. My concern for this patient is …………..”
  • “I saw and evaluated the patient. I reviewed the resident’s note and agree, except…….”
compliance check list48
Compliance Check List
  • Stark and Anti-kickback
    • Never give or accept anything of value as an inducement for referrals.
    • Never give or accept anything of more than $50 in value from another health care entity.
    • Any service provided to or by another health care provider should be paid at market value.
    • Do not refer patients to any designated health care entity in which you have a financial interest.
compliance check list49
Compliance Check List
  • General
    • Write and implement a Compliance Plan.
    • Designate a Compliance Officer.
    • Take reports of potential violations seriously.
    • Never punish an employee for reporting a potential compliance violation.
    • Perform periodic medical record reviews.
no grace period for 2005 or 2006
NO GRACE PERIOD FOR 2005 or 2006

HIPAA gives us another major change

  • Effective October 1, 2005, the 2006 ICD-9-CM codes are to be submitted to all carriers
  • Effective January 1, 2006, the 2006 CPT-4 codes are to be submitted to all carriers.
esophagoscopy upper gi endoscopy and enteroscopy
Esophagoscopy, Upper GI Endoscopy, and Enteroscopy

Esophagoscopy – limited to study of the esophagus.

Esophagogastroduodenoscopy (EGD) - including study of the esophagus, stomach, and either the duodenum and/or jejunum

Enteroscopy (PUSH)- Past the second portion of the duodenum, into the jejunum and up to and including the ileum.

flexible fiberoptic sigmoidoscopy
Flexible Fiberoptic Sigmoidoscopy
  • Intent to only visualize the rectum, anus, sigmoid, descending and can include the splenic flexure.
  • When a colonoscopy is discontinued prior to the splenic flexure, it is still to be billed as a discontinued colonoscopy when the initial intent was colonoscopy.
  • Most ASCs and outpatient departments do not get financial payment for FFS since it is considered an office based procedure.
  • The scope goes beyond the splenic flexure
  • If done on a patient with a good majority of colon removed, it can still be billed as colonoscopy with reduced service modifier 52
  • If done on a patient with j pouch, Hartmann’s pouch, etc., bill the pouchoscopy codes.(44385)
endoscopic biopsy
Endoscopic Biopsy
  • This code should be reported only one time regardless of the number of biopsies performed. If multiple biopsies are performed in different areas of the upper GI tract, the most extensive biopsy would be reported.
endoscopic biopsy57
Endoscopic Biopsy
  • If one lesion is biopsied and a separate lesion (from another site in the intestine) is removed during the same session by means of a separate technique other than the biopsy, it would be appropriate to report a code for the biopsy of one lesion and an additional code for the removal of the separate lesion.
endoscopic biopsy58
Endoscopic Biopsy
  • The use of –59 modifier is essential when biopsy for one lesion and removal of a separate lesion with a different technique. The modifier is added to the biopsy lesion.
  • If a Clo-test (test for Helicobacter pylori), is performed, this is correctly billed as a biopsy.
endoscopic hot biopsy removal
Endoscopic Hot Biopsy Removal
  • The number of lesions removed by hot biopsy are not reported separately
  • Different techniques at different sites within the intestine can be reported with the appropriate modifier.
  • Anoscopy includes hot biopsy and snare in the description
endoscopic snare removal
Endoscopic Snare Removal
  • The number of lesions removed by snare are not reported separately
  • Different techniques at different sites within the intestine can be reported with the appropriate modifier.
  • Can be cold or hot snare
endoscopic ablation of lesion
Endoscopic Ablation of Lesion
  • This code is reported only one time for any number of lesions removed by the above techniques.
  • Can be used on sessile polyps, AVMs (arteriovenous malformations), or other suspicious areas within the GI tract.
  • Can be accomplished by APC (argon plasma coagulation) among some of the methods.
endoscopic lesion removal
Endoscopic Lesion Removal
  • The appropriate code for lesion removal and/or ablation are selected based on techniques of removal.
  • They are to be reported only once per operative session regardless of the number of lesions treated using that treatment method.
  • Check the operative report carefully to verify the technique used to remove the lesion(s).
endoscopic lesion removal63
Endoscopic Lesion Removal
  • Multiple lesions may be removed using different techniques, i.e., snare, hot biopsy, ablation. If different techniques are used in separate areas of the GI tract, choose the codes that describe each technique used.
  • The second, third, fourth, etc., techniques are listed with a –59 modifier to indicate a separate site within the intestine when the component code is bundled into the most comprehensive code.
endoscopic retrograde cholangiopancreatography ercp
Endoscopic Retrograde Cholangiopancreatography (ERCP)
  • The common bile duct is cannulated, dye injected, and the biliary tree is visualized.
  • The collection of specimens by brushing or washing is included in reporting this code.
  • Multiple techniques are reported without the 59 modifier. Exception: Insertion of more than one tube or stent can be reported necessitating the 59 modifier when applied to 43268 and 43269.
tips for endoscopy reports
Tips for Endoscopy Reports
  • Make sure that there is a pre-operative and post-operative diagnosis. Even if the endoscopy is negative, go back to the original reason for the procedure as the diagnosis for the endoscopy.
  • Be specific as to how the biopsy/polypectomy was performed; i.e., snare, hot biopsy forceps, ablation, etc. The phrase multiple polypectomies does not give us enough information to submit a claim.
tips for endoscopy reports66
Tips for Endoscopy Reports
  • LOCATION! LOCATION! LOCATION! In order to get paid for different techniques in different sites within the intestine, the location of the lesion is essential in order to apply the appropriate modifier -59.
  • If a Clo-test was done, this is billed as a biopsy. Make sure that this is mentioned in the report. Too often, this is only contained in pathology
tips for endoscopy reports67
Tips for Endoscopy Reports
  • Wait for pathology report before assigning diagnosis code. Neoplasm uncertain behavior does not mean that the area looks suspicious, it means that there is atypia or dysplasia. Suspect Crohn’s disease does not mean you have Crohn’s disease.
  • MOST IMPORTANT!!!! The procedure note has to be legible. The solution: DICTATE YOUR NOTE!!!!
tips for endoscopy reports68
Tips for Endoscopy Reports
  • If 25 biopsies were taken during the session, please make sure to also add how much additional time this took you to do. The same applies to multiple polypectomies by snare or hot biopsy, etc. The book states biopsy(s), polypectomy(s), so this means you can’t bill more than one code. If your documentation states how much extra time and how much more difficult this procedure was, a -22 modifier can be added to the claim.