Gastroenterology Coding Alert

Examine the outcomes from this comparative billing report for the scoop.

Gastroenterologists are among the most frequent billers of upper and lower endoscopies — but does frequency equate to accuracy?

That’s what auditors sought to determine as part of a new comparative billing report (CBR) compiled by RELI Group, Inc., which CMS contracts to develop, produce, and distribute CBR reports. The firm undertook an investigation after learning that upper endoscopy procedures had an improper payment amount of $6.5 million in 2018, said RELI’s Annie Barnaby during a Sept. 24, 2019 presentation on the topic.

In addition, she noted, a recent journal article indicated that about 30 percent of bidirectional endoscopy procedures were performed on different dates of service. “So, we can see from the result of that CERT analysis and the article that there is a potential issue with the high amount of improper payments for upper and lower endoscopy procedures,” she said.

To tackle this issue, RELI aimed to “review statistics for rendering providers who performed upper and lower endoscopy procedures for which a Medicare Part B claim was submitted,” she said. The resulting analysis included CPT^® codes for upper and lower endoscopy procedures.

Here’s What the CBR Evaluated

RELI reviewed claims submitted for patients who underwent both upper and lower endoscopies on separate dates between May 1, 2018 and April 30, 2019. The firm then evaluated providers whose charges for these services were “significantly higher compared to state or national percentages or rates,” she said.

Why this matters: When appropriate, it’s more cost-effective (and often better for patients) to perform upper and lower endoscopy on the same date. Booking a second service for the subsequent procedure results in additional physician and facility fees, according to a May 2019 report in JAMA Internal Medicine. Although it isn’t always the case that physicians schedule the services separately to collect higher reimbursement amounts, this issue is on CMS’ radar screen as a potential way for physicians to fraudulently increase their income.

Remember: The feds use CBRs as a tool to offer insight into billing and coding trends across different specialties and healthcare settings. CMS partners with its contractor, RELI, to produce the reports, which you can find at  cbr.cbrpepper.org. You can use the data from the CBRs to see where you stand when it comes to the frequency of billing certain services, codes, or modifiers — and more importantly, utilize these peer measurements to eradicate your coding problems.

Check out the Findings

When evaluating the percentage of claims billed for upper/lower endoscopies performed on different service dates, the national average was 16.26 percent, but in one case, a provider “performed upper/lower endoscopy procedures on different dates of service 66.67 percent of the time during the review year,” Barnaby said. “So this provider had an outcome of significantly higher for both the state and national comparison in this metric.”

In some states, the average fell below the national metric — for instance, the average percentage for claims billed on separate dates for upper and lower endoscopy was just 4.62 percent in Oregon. However, it was a startling 36.47 percent in New Jersey, which is more than double the national average.

Check Where You Stand

You can go through your own records to identify when your practice performed separate-day upper and lower endoscopies. Then you can compare that percentage to the national and state averages. If you see that you’re an outlier, it could be a good idea to dig deeper into the data and determine exactly what you could have done differently.

Resource: To read more about the CBR on this topic, visit  cbr.cbrpepper.org/About-CBR/CBR-201910.