Gastroenterology Coding Alert

Question: Does the CPT^® code determine the reimbursement rate or does the ICD-10 code? I thought it was the CPT^® code, but I keep hearing that our GI practice’s pay could suffer if we don’t use the right ICD-10 codes, so I’m confused.

New Hampshire Subscriber

Answer: The CPT^® code on your claim determines your reimbursement rates under Part B Medicare.

On the other hand, ICD-10-CM codes support medical necessity for every procedure code on your claim — without them, insurers can’t justify paying you for the services your physician performs. Therefore, if you use nonspecific or incorrect diagnosis codes, your pay definitely could suffer, because your insurer might determine you didn’t perform a medically necessary service and you therefore aren’t entitled to payment for it.

Sometimes an ICD-10 code will be the cause of non-payment, however, such as when as an asymptomatic Medicare patient makes a visit prior to a colonoscopy to discuss arranging for the procedure; in absence of symptoms or disease to justify the visit, reporting the colon cancer screening code would not be a Medicare-covered service. The patient could be held to pay for the visit by use of an Advanced Beneficiary Notice (ABN).