Specialized Gastroenterology Billing Services

Our GI specialists meticulously distinguish screening from diagnostic colonoscopies based on indication, history, and documentation. For screening colonoscopies that convert to diagnostic (polyp found and removed), we apply modifier PT to the surgical code and ensure proper diagnosis linkage. We navigate Medicare's NCD for colorectal cancer screening, ACA-mandated first-dollar coverage rules, and commercial payer-specific screening vs. diagnostic policies to maximize reimbursement and minimize patient surprise.

When multiple procedures are performed during a single EGD session — such as biopsy, dilation, and control of bleeding — we apply the appropriate multiple procedure rules. We identify the highest-valued primary procedure and apply the appropriate NCCI edits and multiple procedure modifiers (51, 59, XU) as needed. Our coders ensure documentation supports each distinct procedural component and that all medically necessary services are appropriately captured and billed.

ERCP coding requires precise distinction between diagnostic (43260) and therapeutic components. We code based on the specific interventions performed — sphincterotomy (43262), stone extraction (43264-43265), stent placement (43267-43269), and biopsy (43261). Our specialists handle the complexities of coding for multiple therapeutic interventions during a single ERCP session, proper use of add-on codes, and documentation requirements for medical necessity of the procedure.

Biologic therapy billing is a core competency of our GI service. We handle the complete lifecycle: prior authorization and step therapy management, J-code billing for each biologic (J1745 infliximab, J3380 vedolizumab, J3357 ustekinumab, etc.), infusion administration coding based on duration (96413 for first hour, +96415 for each additional hour), and drug unit tracking. We also manage patient assistance program billing and Medicare Part B vs. Part D coverage determinations.

We handle the full spectrum of advanced GI diagnostic testing. Capsule endoscopy coding (91110 for small bowel, 91111 for esophagus) requires proper use of G-codes for Medicare and awareness of payer-specific LCDs. We also bill for esophageal pH monitoring (91034-91038), anorectal manometry (91117), esophageal manometry (91010-91013), and hydrogen breath tests (91065). Each of these studies has unique coding rules, documentation requirements, and payer coverage policies.