Complete Guide to Gastroenterology Billing Process and Revenue Management

Gastroenterology focuses on patients who suffer from gastroenterology issues, handle tests, scopes, and many follow-ups. Running a gastroenterology practice is difficult, however the billing of the services matter the most. Clean claims always ensure a seamless billing process that forms the financial foundation of your business. A clean claim contains accurate codes with comprehensive notes.

Gastroenterology billing requires specialized understanding and accurate documentation of details. It involves many diagnostic and therapeutic procedures. It is essential to select the supporting documents, correct CPT codes and modifiers for each individual procedure. Errors like improper coding and documentation leads to denials that can impact the flow of revenue.

Below are the steps of gastroenterology billing process:

Demographic entry and Insurance Verification

The primary focus out here is to ensure accurately collecting patients’ demographic like personal details such as name, address, date of birth, and contact information. Additionally, it is essential to check whether the patient is covered under the insurance plan along with the patient history.

Medical Coding

Medical coding plays a vital role as assigning proper CPT codes, ICD-10 codes and HCPCS codes for procedures like colonoscopy, EGD, sigmoidoscopy, or push enteroscopy assist with a seamless billing process.

Prior Authorization

Prior authorization is one of the important steps in the billing process as sometimes obtaining approval from a patient’s insurance company is necessary before performing certain gastroenterology procedures. Some of the procedures that require prior authorization include colonoscopies, endoscopies, capsule endoscopy, biopsies, etc.

Gastroenterology Coding

It is essential to use accurate codes for the services rendered like CPT, ICD-10, and HCPCS codes. Accurate coding is essential for complex procedures like colonoscopies, ERCP and biopsies. For example,

• Colonoscopy: CPT codes in 45378–45398
• ERCP: CPT codes in 43260–43278
• Biopsies: 45380 for colon biopsy

Charge Entry

Charge entry is the procedure of entering all the services provided into the billing system. It includes procedure codes, units, provider details, and facility information. Proper charge entry makes sure claims replicate the services rendered without errors or omissions. On time payment and smooth revenue cycle management can be achieved through accurate entries.

Claim Creation and Verification

When creating a claim, healthcare providers record all the procedures involved. These are then documented into an insurance claim that is ready for submission to the insurance payer. It is then reviewed for finding any coding errors, missing information or payer-specific compliance issues.

Claim Submission

Timely submission of claims allows providers to receive payment from the insurance company. These claims contain accurate and appropriate documentation, coding and patient data.

Payment Posting

It is the process of recording the payment received from both the patient and insurance companies on the patient accounts. It links the EOB (explanation of benefits) with the provider's charges and confirms that proper reimbursement has been given. Accurate posting provides practices with consistent view of all outstanding patient balances. Additionally, it gives a clear picture of the amount of accounts receivable.

Denial Management

Denial management involves addressing claims that have been denied by the payers or are underpaid due to incorrect claim submission. The billing experts determine reasons for denial and correct errors that allow them to resubmit claims or appeal. Effective denial management helps recover lost revenues, improves collections and helps identify trends in future denials.

Follow-up on Accounts Receivable (A/R) in Gastroenterology Billing

A/R follow-up is the process of tracking, reviewing, and resolving all unpaid or delayed insurance and patient balances. It ensures the providers receive full and timely reimbursement for gastroenterology procedures.

Payment Collections

The process involves generating statements for copays, deductibles, and balances. By effectively managing the billing processes, overdue accounts receivables are minimized. As a result, it increases the possibility of better cash flow.

Compliance Monitoring and Audit

It is critical to ensure the practice follows all HIPAA regulations, CMS regulation, payer-specific regulations, etc. This allows the practice to review coding, claim forms, documentation, billing, etc. and find errors, problems, and inefficiencies. Regular audits allow the practice to identify claim denials, minimize the potential for penalties, and maximize the practice's credibility.

In order to make the gastroenterology billing process seamless and avoid claim denials and improve revenue generation it is often important to outsource the services to professional billing experts.

Importance of Outsourcing Gastroenterology Billing Services

Outsourcing the gastroenterology billing services makes substantial difference to the financial health and operational efficiency. The outsourced billing experts are certified medical coders, denial managers, and prior authorization specialists who have advanced knowledge in coding, and payer specifications. RCM partners can process claims more effectively, quickly, and with fewer payment delays.

Gastroenterology billing outsourcing helps save substantially in expenses. Practices can save approximately 80 percent in operational costs, with rates starting as low as $7/hour. Additionally, outsourcing reduces practices of the administrative burden. This helps physicians and clinical staffs to care for their patients.