American College of Physicians: Internal Medicine — Doctors for Adults ®


Expert hints at how GI practices can keep coding current

From the September ACP Internist, copyright 2009 by the American College of Physicians

By Paula S. Katz

As Medicare looks to trim costs, more claims are being rejected that previously had been acceptable, according to Cecile M. Katzoff, vice president for practice management and consulting services for the American Gastroenterological Association. Ms. Katzoff talked to ACP Internist about what doctors need to know to get their billing and coding back on track.

Q: What’s driving the increased scrutiny of claims?

A: The Centers for Medicare and Medicaid Services has estimated that over $10 billion has been paid by Medicare for services incorrectly billed or insufficiently documented. Some of these claims were for services provided by nurse practitioners and physician assistants (midlevel providers). Ten years ago, there were no midlevel practitioners in GI practices. But as [midlevels] became more and more the norm, driven by the shortage of GI physicians, practices didn’t know what to do with them or how to bill for them. Another issue identified by CMS as billed incorrectly is Consultations.

Q: Are practices really being audited more?

A: Yes. Audits are high on people’s radar because they are, in fact, being audited more than ever. Medicare’s Recovery Audit Contractors are asking for documentation because of the amount of money being paid incorrectly. Practices used to be audited because they were doing something really egregious or someone reported them. Now the average practice that thinks it is doing everything right has a good chance of being audited as well. (Learn how to prepare for the nationwide rollout of Recovery Audit Contractors in the June issue of ACP Internist.)

Q: What are the biggest coding mistakes and how can they be fixed?

A: Confusion surrounds the “incident to” provision and teaching physician guidelines. For billing, the physician whose name appears on the claim must be the person who provided the service. If the name on the claim is not the doctor who provided the service, that’s considered a false claim unless the service meets one of the two exceptions. Because there are a lot of misunderstandings about it, physician offices are not following the rule correctly and are putting themselves in jeopardy.

Q: How should the “incident to” provision work?

A: It allows a physician or nonphysician provider to bill for service that he or she didn’t actually provide, but only under very specific conditions. The first requirement is that the person providing the service must be an employee of the physician or group. The second requirement is that the person whose name appears on the claim must be present in the office suite when the service is provided. The third requirement is that the service must be part of a course of treatment prescribed by one of the physicians in the group. So “incident to” only applies to an established patient visit after an initial service has been provided by a physician in the office.

Q: Why has this become a problem now?

A: First, the “incident to” provision is not intuitive. Next, even though it has been around since Medicare was created in the 1970s, it has received very little press and often may not be known at all or misunderstood.

Now that physician assistants are being used more, this is being billed incorrectly more. For example, at a new consult a midlevel provider documents the patient history, performs the examination and proposes a treatment plan. The doctor comes in, confers with the midlevel and bills under the doctor’s number. That is not the proper procedure. The doctor has to see the patient first, do the examination and document it, determine a treatment plan and only then bill under his number. Then the midlevel can do the follow-up visit, implement the treatment plan and bill using the doctor’s number, even if he or she is not in the suite.

Q: What is the confusion about teaching guidelines?

A: Teaching guidelines allow physicians to bill for a service where a resident or fellow is participating even if it is a new patient or consult, as long as the physician addresses the history, examines the critical area and then documents that he agrees with or amends the treatment plan of the resident or fellow. A physician can’t bill for that consult or new patient seen by a midlevel.

Q: Why do practices mix up the two?

A: They are both situations where a physician attempts to bill for a service provided by someone else.

Q: How did CMS’ addendum to the “incident to” requirement for a shared service in the hospital complicate this?

A: Consultations can never be shared, but other outpatient or inpatient visits in the hospital can be as long as the physician sees the patient on the same day. Take the case example of a midlevel who is rounding on patients on subsequent hospital visits and documents the examination and history, or maybe changes the orders. Then the physician comes in and sees the patient. The physician can bill for the combination of visits in the hospital under the physician’s number and get 100% of the reimbursement.

Q: What else are auditors targeting?

A: Consultations versus new patient visits is very high on the Office of the Inspector General’s hit list, because it is very often billed incorrectly and not documented sufficiently. Consultations pay more than any other E/M service and doctors, particularly specialists, intuitively think that every patient that they see they can bill as a consultation. However, a consultation requires a request from another physician for an evaluation and opinion, and you have to send a letter back to the requesting physician. It is not a visit resulting from a referral from another physician for a procedure or for a patient who is self-referred.

Q: How should offices handle not having a CPT code?

A: The only option is to bill an unlisted procedure code. If physicians frequently perform a procedure for which there’s no code, for example, a new procedure, contact the payer to come up with a method of billing for it, such as a dummy code. If the code is unlisted, it takes longer to get paid because it has to be manually reviewed and priced.

Q: What are other common problem areas?

A: Diagnostic tests and infusions are only billable by the physician who is in the office when the service is provided, not a technician or employee doing the test. The problem is that often practices are giving credit to the physician who ordered the test and not the physician who was there when it was performed.

Also, many doctors want to see a patient before a screening colonoscopy but unfortunately there’s no way to get reimbursed for that visit. As a result, practices screen patients over the phone and schedule the procedure without having the patient come into the office. Others have midlevels see the patient and don’t bill for the visit.

Q: What challenges are ahead?

A: The ICD-10 is being implemented and there will be a whole new system of assigning codes to diagnoses. It is going to require system changes to be able to accept the new codes; then everyone will have to be trained on how to select the codes correctly and how to bill correctly. (Learn more about how the entire office can stay up-to-date on the new ICD-10 codes in the July/August issue of ACP Internist.)

Q: How can gastroenterologists prevent problems in the future?

A: I don’t expect physicians to read through the Medicare manual, but they need to make sure they and their staff are appropriately trained in billing and coding at least once a year. They also should do their own internal audits or have someone from the outside do it once a year to be sure they’re doing it correctly. If you find problems, you need to fix them before somebody else finds them.



For more information

More information on split and shared E/M services is online.

Background information about revisions to “incident to” rules is online.

For clarification of consultation definitions, see here and here.



Top 10 GI coding problems—and how to get them right

You’re not alone if you’re having coding problems, according to Cecile M. Katzoff, vice president for practice management and consulting services for the American Gastroenterological Association. Ms. Katzoff discussed those problems and how physicians should address them during her presentation on “The 10 Most Common Coding Conditions That Cause Consternation and Confusion for Gastroenterologists,” held at Digestive Disease Week in Chicago.

Starting with what Ms. Katzoff called “the most misunderstood” issue, but otherwise in no particular order, here are those top 10 issues and her advice on each.

1. Shared services. The most misunderstood concept in coding is what qualifies as “incident to”—services provided by one person but billed under another. The bottom line is that a physician must personally perform an initial service and remain actively involved in the course of treatment. A shared service is allowed for hospital visits other than consultations in which the physician provides any portion of the encounter face-to-face.

2. Diagnostic tests and infusions. While a physician doesn’t have to be physically in the patient’s room when the patient is receiving these services, he or she must be in the office suite providing what is called “direct supervision.” The service must then be billed under that physician’s number—not the ordering physician if that is someone else.

3. Consultations versus new patient visits. Consultations require a documented request from another physician for an evaluation regarding a problem and a letter back to the requesting physician summarizing findings and recommendations. New patients are defined as those who are self-referred or referred for a procedure to evaluate a problem or to transfer care and who have not received any face-to-face service by anyone in the practice for at least three years.

4. Visit preceding screening colonoscopy. Although physicians may want to see patients before a colonoscopy, these visits can only be billed as preventive medicine service.

5. Surgical modifiers for physician billing. There are misunderstandings about when to use a modifier and which to use. Here’s how it works.

  • 51: Only use if instructed by payer; doesn’t affect reimbursement;
  • 59: Use for procedures bundled into another procedure under the Correct Coding Initiative edits;
  • 62: Use when two physicians participate in the placement of a percutaneous gastrostomy tube, code 43246;
  • 22: Use for unusual procedure;
  • 73: Use for discontinued procedure prior to anesthesia administration; and
  • 74: Use for discontinued procedure after anesthesia administration.

6. Biopsies and polypectomies. The confusion here is in determining when you can and cannot bill multiple codes. One method for multiple lesions and multiple methods on the same lesion go under one code. Multiple methods for different lesions go under multiple codes and need the 59 modifier if bundled. Removing a polyp using cold biopsy forceps is billed as a biopsy. You cannot bill for control of bleeding caused by biopsying or removing a lesion.

7. E/M service and procedures on the same day. You can bill for both if you see the patient, evaluate him, and decide to do a procedure on the same day; the E/M service requires a 25 modifier. The E/M visit is not billable prior to a scheduled open-access procedure.

8. Services billable in a Medicare-certified ambulatory surgery center (ASC). Medicare will only pay for procedures CMS has approved to be done in an ASC and not for diagnostic tests that are supposed to be performed in the office, like breath tests or CT scans.

9. No CPT code. Don’t use a code that doesn’t define what you do. Instead, use modifier 22 or 52 or an unlisted procedure code when the procedure doesn’t fit an existing CPT code. Each claim must include a procedure report and detailed description of what was done beyond existing definitions.

10. Incomplete procedure modifiers. Differentiate between the following: 53 is for Medicare screening or diagnostic colonoscopy that doesn’t view beyond the splenic flexure; 52 is for all other procedures that don’t meet CPT definition.


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