Did you know that gastroenterology, specifically gastrointestinal (GI) healthcare expenditures totaled $111.8 billion in 2021 alone? Besides, GI diagnoses and symptoms resulted in 14.5 million emergency department visits and 2.9 million hospital admissions.
Undoubtedly, gastroenterology practices handle high-volume and high-cost procedures on a day-to-day basis. However, despite these staggering figures, the denial rate and revenue leakage are high.
This guide aims to change that. It explores gastroenterology revenue cycle management (RCM) guidelines, key challenges, and best practices.
So, continue reading!
Why Revenue Cycle Management Matters for Gastroenterology?
For healthcare practices, gastroenterology revenue cycle management matters because of the specialty’s unique procedural volume, administrative requirements, and high unit costs. As discussed below:
Complex Screening-to-Diagnostic Conversions
What happens when the provider removes a polyp or performs a biopsy during a routine preventive screening colonoscopy? It converts the procedure from screening to diagnostic.
When this happens, if the billing team fails to append modifier PT (for Medicare) or 33 (for commercial payers), it can negatively impact the practice’s financial performance. How? It triggers immediate claim denials, invalidates preventive coverage benefits, and causes unexpected out-of-pocket costs for patients.
Strict Coverage Policies & Coding Rules
For context, endoscopies are subject to multiple endoscopy base-code pricing rules and strict National Correct Coding Initiative (NCCI) edits.
However, if you implement an effective gastroenterology RCM process, you can easily prevent underpayments and unnecessary bundling.
Simply put, RCM in gastroenterology practices safeguards its financial health by ensuring providers receive rightful reimbursements.
Dual-Component Billing Alignment
Do you know that endoscopy procedures are often split between the physician professional fee, hospital or ambulatory surgery center (ASC) component, and pathology lab charges?
How does the gastroenterology RCM process help? It aligns all three claims to avoid cross-entity denial loops or mismatched place-of-service (POS) codes.
Frequent Prior Authorization Bottlenecks
Insurance payers require gastroenterology practices to obtain prior approvals for core procedures. These include Endoscopic Retrograde Cholangiopancreatographies (ERCPs), capsule endoscopies, and biologics for Inflammatory Bowel Disease (IBD).
This means that when billing these procedures, the medical claim must include a valid and active authorization number. Missing it will result in immediate denials.
So, how does GI-focused RCM help here? It establishes strong pre-authorization workflows to protect your practice from high-dollar claim denials.
High Financial Impact of Minor Leakage
Note that gastroenterology relies heavily on procedure-based, high-dollar encounters. These include screening colonoscopies, diagnostic upper endoscopies, biopsies, and polypectomies.
Since these procedures carry substantial monetary value, even a 1% to 2% claim denial or leakage rate translates into tens of thousands of dollars in revenue leakage. However, tailored gastroenterology RCM can prevent it.
Gastroenterology Billing Rules & Payer Guidelines
Discussed below are the main gastroenterology-specific payer guidelines and billing rules:
- You can bill average-risk screening colonoscopies covered under HCPCS G0121 once every 10 years for a single patient, as per Centers for Medicare & Medicaid Services (CMS) guidelines.
- What happens when a patient is at high risk? For example, a personal history of adenomatous polyps, family history of colorectal cancer, or inflammatory bowel disease. In such circumstances, the coverage limit of screening colonoscopies (HCPCS G0105) increases to once every 2 years.
- Under the Affordable Care Act (ACA), Medicare and private plans are required to cover average-risk preventive colorectal cancer screenings starting at age 45. Besides, the ACA mandates payers to ensure zero patient cost-sharing.
- NCCI edits restrict unbundling when multiple GI endoscopy services are performed during the same encounter.
- Local Medicare contractors (such as Noridian, Novitas, and Palmetto) enforce coverage rules called local coverage determinations (LCDs). Their main role is to set valid reasons for non-screening GI procedures in each state.
- For example: You must list specific primary ICD-10 diagnosis codes for diagnostic EGDs (43239) or non-screening colonoscopies (45378) to establish medical necessity.
- Keep in mind that professional reimbursement for gastroenterology procedures varies significantly based on the POS code on CMS-1500 claims.
- For example: A non-facility claim with POS 11 (office) yields higher professional RVU reimbursement to cover overhead, supplies, and equipment costs. Conversely, facility claims with POS 24 (ASC) or POS 22 (on-campus outpatient hospital department/HOPD) reimburse lower professional fees. This requires separate facility charge submissions (UB-04) by the facility entity.
- ACA recognizes dedicated anesthesia services as an integral part of the preventive benefit when ordered by the endoscopist. This means private payers and Medicare cover screening anesthesia without patient cost-sharing when billed with modifier 33 or PT.
Key Gastroenterology RCM Challenges
The following are some of the key challenges that gastroenterology RCM specialists encounter:
- When a preventive screening colonoscopy is converted to a diagnostic procedure, missing or misapplying modifiers can lead to denials or improper patient cost-sharing.
- Gastroenterology RCM experts must ensure alignment with medical necessity guidelines and primary procedure coding when billing dedicated anesthesia separately.
- Billing before pathology results are obtained risks diagnosis mismatch denials. On the other hand, waiting for pathology findings to assign accurate diagnostic codes creates charge capture lags. This makes gastroenterology revenue cycle management more challenging.
- RCM specialists at gastroenterology practices must ensure proper application of modifier 53 when a procedure is discontinued due to inadequate bowel preparation. Missing it can result in lost partial costs and trigger denials.
- When the provider renders multiple endoscopies or biopsies across distinct anatomical sites in one session, the gastroenterology RCM specialist must append modifier 59/XS. Otherwise, it can result in unnecessary payer bundling and underpayment.
- Mismatches between professional claims (CMS-1500) and facility claims (UB-04) across ASC or HOPD result in downcoding or reimbursement delays.
Best Practices to Improve Revenue in Gastroenterology
Let’s review some effective strategies to optimize your gastroenterology revenue cycle management:
Ensure Eligibility Verification & Pre-Authorization
Always start by strengthening your front-end operations. That is, verify patient eligibility and payer approvals for all elective endoscopies and infusion biologics at scheduling and before the patient encounter.
Train Staff on Screening-to-Diagnostic Conversion
If you want your gastroenterology RCM workflow to yield positive results, then train your staff to use modifiers 33 and PT accurately.
How does it help? It prevents conversion-related claim rejections and patient cost-sharing benefits.
Standardize Documentation
Guide the endoscopists to document the exact anatomic location, size, number of polyps, and specific removal techniques in operative notes.
This gastroenterology RCM practice ensures clear procedural distinctions and protects against unnecessary bundling.
Leverage Claim Scrubbing Tools
Utilize automated claim scrubbing tools. The reason? It will help you identify invalid ICD-10/CPT pairings, unbundling issues, and missing modifiers before claim submission.
Besides, track your gastroenterology RCM key performance indicators to quantify your monthly and annual performance. To name a few, clean claim rate, first-pass rate, and collection ratio.
Implement Denial Management Workflow
Denial management is a key component to prevent revenue leakage. Thus, categorize, track, and appeal denials immediately upon receipt.
Also, use quarterly denial analytics to identify recurring root causes. The insights will help you improve your overall gastroenterology RCM workflow.
Reconcile Payment Postings
Never forget to systematically cross-check electronic remittance advice (ERA) payments against negotiated fee schedules. This will help you identify issues such as downcoding, underpayments, and multiple-procedure reductions.
How Does Outsourcing RCM Help Gastroenterology Practices?
To summarize, gastroenterology RCM guidelines include proper use of modifier 33/PT, understanding of the multiple endoscopy base-code pricing rules, and NCCI edits. Besides, you should leverage automated scrubbing tools to ensure a higher clean claim rate.
With that said, partnering with a professional RCM company can provide practices with access to specialty-specific expertise that generalist billers often miss.
Moreover, gastroenterology-focused teams, like the one we have at MediBillMD, have in-depth knowledge and hands-on experience with screening-to-diagnostic conversion modifiers, NCCI edits, pre-authorization mandates, and split billing rules.
Thus, if you want to protect your practice revenue, feel free to outsource gastroenterology billing services to MediBillMD.
