How Do GI Coding Changes Affect the Field? Reimbursement, Technology, Denials & More
Praveen Suthrum, president and co-founder of NextServices, explains what these changes mean for gastroenterologists and GI-driven ambulatory surgery centers.
Increased need for specificity
Demand for specificity has been an escalating trend in healthcare as newer techniques gain momentum. Physicians are facing the need to provide more information for coding purposes. For example, in the past esophagoscopy was associated with general codes. In the 2014 CPT code set, physicians must specify whether the scope was introduced transorally or transnasally and if the scope was rigid or flexible.
The increased need for specificity represents a paradigm shift in the field of gastroenterology. "The increased specificity is moving gastroenterologists towards newer ways of looking at diagnoses and patient treatment," says Mr. Suthrum. The overall trend is driving physicians to take a closer look at their patients and their documentation.
Reimbursement: up or down?
Reimbursement pressure is a concern felt across the healthcare continuum and with so many code changes reimbursement fluctuation is inevitable. "Many GI-driven ASCs and gastroenterologists rely on traditional endoscopy and colonoscopy," says Mr. Suthrum. "Continuing to do so will affect reimbursement." These procedures have been high volume and profitable in the past, but it is these procedures that will begin to face more reimbursement pressure in the years to come because they are now mainstream.
On the other hand, there are 26 new codes, some of which represent new opportunities for reimbursement. For example, there is now a code for endoscopic mucosal resection. Medicare is reimbursing for this new code, and typically once Medicare reimburses for a procedure, commercial payers will follow suit. "From an opportunity standpoint, a group of gastroenterologists at an ASC should actively specialize in new techniques," says Mr. Suthrum. "Someone should focus on EUS and someone else on newer approaches to EGD or esophagoscopy." Diversification of GI procedures amongst physicians allows for a broader, and more reliable, reimbursement base.
Keeping up with technology
Not all new procedures in the GI field have earned steady reimbursement, but keeping abreast of technological advances is a beneficial strategy for gastroenterologists. "Gastroenterologists must keep up with new technology," says Mr. Suthrum. "If they don't, they can be quite sure of a long term decline in reimbursement." While reimbursement for traditional procedures may face a decline in new reimbursement, new technologies could come to fill that void.
"Once upon a time there was no video capsule endoscopy," says Mr. Suthrum. "But what if it could partially replace small bowel endoscopies, even though many physicians do not think so." At the rapid pace with which technology advances it is not difficult to imagine a capsule and its software that could spot and highlight polyps that the human eye would miss. "What if that technology comes [and the codes to go with it]? Imagine a physician that hasn't even explored new techniques," he says.
Getting back to the basics
A fear of increased denials accompanies any significant coding changes, but that fear does not need to become a reality. "If ASC leaders do the basics correctly, a lot of denials will be avoided," says Mr. Suthrum. Basic measures to carefully execute include:
• Obtaining proper authorization
• Understanding patient benefits and eligibility
• Working for clean, accurate physician documentation
• Submitting clean claims in a timely manner
While the 2014 code set went into effect on Jan. 1, reimbursement is not necessarily streamlined. "Use basic reporting and track reimbursement. Compare it to last year," Mr. Suthrum says. There could be errors on the payer side, such as underpayment or lack of recognition of a new code.
"It is one thing to read about something, but another to live with it on a day-to-day basis," says Mr. Suthrum. "It can be difficult for physicians to keep up-to-date with all of these changes." Administrators can step in and help their physicians through the process. Hold regular meetings to discuss denials issues. "Be proactive," says Mr. Suthrum. "These simple things can go a long way in avoiding denials."
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