The Best Practices for Gastroenterology Billing Success

Proper billing is the foundation of the financial health of any gastroenterology (GI) practice. Because of the unique character of GI services—ranging from complex procedural coding to constant payer policy revisions—gastroenterology billing demands precision, detail, and constant process improvement. Without a well-thought-out plan, even minor mistakes have the potential to create enormous payment delays, increased denials, and lost revenue.

Following are some best practices established to help GI practices automate their billing, reduce errors, and improve overall revenue cycle performance.

1. Proper Documentation: The Pillar of Accurate Billing - The importance of accurate, thorough clinical documentation cannot be overstated. Proper documentation has a direct bearing on coding, claim filing, and, in turn, reimbursement. In fact, a gastroenterologists should ensure that their notes include:

• The specific preoperative indication for requesting the test (e.g., screening vs diagnostic)
• Report of the procedure performed, whether any therapeutic intervention like polypectomy, biopsy, or hemostasis was performed results and impressions, using particular terms consistent with ICD-10 coding
• Post-procedure diagnosis and follow-up recommendations.

Like in case of a colonoscopy performed due to a family history of cancer of the colon (Z80.0) should be distinguished from a diagnostic colonoscopy for symptoms like rectal bleeding (K62.5). This impacts coding the service and whether or not it may be coded preventive or diagnostic, and which impacts patient responsibility and payment. Also, every one of the CPT codes billed must be supported by the respective ICD-10 codes. Procedure versus diagnosis code discrepancies are one of the leading reasons for payer denials.

2. Pre-Bill Audits: Preventing Mistakes before Filing - Pre-bill audits are one of the most effective ways of catching and repairing defects prior to claims exiting the office. Pre-bill audits can identify:

• Lack of indications or findings, which are record gaps
• Missing or inappropriate modifiers, particularly those identifying multiple procedures or actions at a location
• Lack of prior authorizations, typical with private insurers

By identifying these issues beforehand, practices can correct errors before claims denial or delay. Edit checks in computer billing programs can achieve this automatically, but it does require a human check, particularly for complex cases or unusual billing scenarios. A strong pre-bill review process also enhances the rate of first-pass resolution, minimizing rework and increasing cash flow.

3. Keep Current With Payer Policies: Avoid Being Caught Off Guard - Gastroenterology practice billing guidelines are updated by Medicare and private payers on a regular basis. Revisions will typically affect:

• Definition of preventive vs. diagnostic colonoscopy
• Whether it is billable by itself
• Bundling and unbundling of routine procedures regulations
• Approved diagnosis-to-procedure code pairs

For example, Medicare deems a colonoscopy performed for personal history of polyps (Z86.010) as not preventive, although the patient is asymptomatic. Private payers may not. Having the facts regarding each payer avoids confusion and appeals.

4. Revenue Cycle Optimization: Track KPIs and Outsource Where Appropriate - Revenue cycle management (RCM) is much more than billing. It encompasses all patient touch points from scheduling through payment. To maximize the process, practices need to track and audit performance on an ongoing basis.

Most critical metrics to track are:

• Days in Accounts Receivable (AR): Indicates how quickly you're being paid. You want this to be under 30 days.
• Denial Rate: Unnecessarily high denial rates generally point to preventable coding or documentation errors.
• Clean Claim Rate / First-pass Resolution Rate: Above 90% means that most of the claims are paid on the first try without editing.

Other Best practices for staying current are:

• Payer and CMS subscription newsletters
• Viewing webinars by such institutions as AGA or ACG
• With coding software or payer portals updated with policy changes
• Continuing education of Gastroenterology billing and coding staff
• Keeping your staff up-to-date prevents unwarranted denials and allows for proper reimbursement of work performed.

If your practice is struggling to reach these standards or lacks GI billing experience in-house, it is time to consider outsourcing. An outsourcing company that specializes in gastroenterology billing can make a big difference, as it comes with added advantage of:

• Access to experienced, certified coders with GI-specific background
• Advanced billing software with denial management features
• Shorter response times and improved collections
• Continuity compliance support

Even practices that have in-house Gastroenterology billing staff can use third-party audits or short-term RCM consultants to determine pinch points and make changes.

Proactive Billing for Predictable Revenue Gastroenterology billing is complex, but it need not be a constant source of frustration. It is no doubt that with good procedures in place, proper documentation, frequent audits, payer policy changes, and good revenue cycle management, indeed GI practices can reduce claim denials, improve cash flow, and enable staff to devote more time to patient care. Ultimately, billing is not a back-office activity - today it's more like a business strategy critical to the fiscal well-being of your practice. Whether one GI practice or operating a large endoscopy center, adopting these best practices will be the path to long-term success.