Gastroenterology Coding Alert

Question: We have been getting denials from Medicaid and other insurance companies for procedures that our gastroenterologist performed. They are stating that the amount has been paid out to the hospital where our gastroenterologist performed the procedure. Is the hospital billing wrong? Please tell me what codes should I bill out such that we get paid for the procedures that our gastroenterologist performed?

Colorado Subscriber

Answer: When your gastroenterologist performs any procedure in the hospital setup, you can claim reimbursements for the procedure performed by using the appropriate CPT® codes. For example, if your gastroenterologist performed a diagnostic EGD, you can bill out 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) to get appropriate reimbursements from the concerned insurance carrier.

The hospital on its part cannot claim the same CPT® code for the procedure. The hospital will only have to bill out the appropriate supply codes to claim for the supplies and instruments used for the procedure. Some CPT® codes have a professional and a technical component. In such a case, both the hospital and your gastroenterologist will be using the same code, but with appropriate modifiers. So, in such a scenario, the hospital will append the modifier TC (Technical component) and you will have to use the modifier 26 (Professional component) to the same CPT® code that you are billing. This will indicate to the insurance company that your gastroenterologist is only billing for his interpretation aspect of the procedure and the hospital is claiming the equipment portion of the procedure.

The only time the hospital can make a claim for the procedure is if your gastroenterologist is on a specified contract with the hospital and the hospital pays out a monthly pre-fixed amount to your gastroenterologist for his services rendered at the hospital.