Gastroenterology billing,
two businesses in one practice.
A GI practice runs an endoscopy suite and, increasingly, an infusion suite. They fail in completely different ways. One loses money to bundling edits and a screening that stopped being a screening. The other loses it the way oncology does.
A screening colonoscopy stops being one the moment you find something
The patient books a screening, you remove a polyp, and the encounter is now diagnostic. The code changes, the modifier changes, and so does what the patient owes, because preventive screening carries no cost share and a diagnostic procedure does. Bill it wrong one way and the practice absorbs the difference. Bill it wrong the other way and the patient gets an invoice they were promised they would never see, which is the call the front desk remembers for a month.
- Screening intent captured at scheduling and carried through to the claim
- Conversion to diagnostic coded with the modifier the payer expects
- Commercial and Medicare screening rules applied separately, because they differ
- Patient cost share explained before the procedure rather than argued after it
The infusion suite is a different business from the endoscopy suite
Crohn and colitis biologics put a GI practice squarely into buy-and-bill: a drug that costs more than the procedure, dosing that varies by product, prior authorization layered across the drug and the site of care, and a payer that decides after the infusion whether it agreed. It is the same machinery as our lead specialty, and it fails in the same places.
- Acquisition model confirmed per payer before the drug is ordered
- Units matched to product and dosing schedule, with wastage reported
- Biosimilar coding kept current with payer preference
- Administration coded from documented chair time rather than from habit
Three techniques in one session is not three claims
Snare polypectomy, cold biopsy and ablation in a single procedure are separately reportable only under specific conditions, and payers apply bundling edits hard. Report them without what unbundles them and the extras deny. Report only the primary and the rest of the work is free. Neither error surfaces unless somebody reads the operative note against the claim, which is not what happens when coding runs off the schedule.
- Operative note read against the claim rather than coded from the schedule
- Distinct techniques and separate lesions supported before anything is unbundled
- Bundling edits checked before submission rather than appealed afterwards
One procedure, four claims, and you control one of them
An endoscopy in an ASC generates a professional claim, a facility claim and usually an anesthesia claim, and pathology adds a fourth when specimens go out. Each carries its own payer rules and its own denial reasons. Practices with an ownership interest in the facility feel every one. Practices without one still take the phone call when the patient opens four envelopes.
- Professional and facility components reconciled rather than worked in isolation
- Anesthesia coverage confirmed per payer, because monitored anesthesia is not universally covered
- Pathology tracked so specimens do not vanish between the lab and the claim
A repeat too soon is a denial with a date on it
Surveillance intervals are driven by findings and enforced by payers to the day. A repeat scheduled inside the interval denies on frequency no matter how sound the clinical reasoning, unless the documentation establishes why the interval does not apply. This one is won or lost at the scheduling desk, weeks before billing ever sees it.
- Interval eligibility checked against the last procedure date before scheduling
- Findings-based intervals distinguished from routine screening intervals
- Medical necessity documented when a shorter interval is clinically indicated
This is what we watch for. How the engagement runs is a separate question.
Before any of it applies to your practice we read your aged A/R and the last quarter of remittance advice, and you get the findings in writing including what we think is not worth chasing. You keep your practice management system, your payer contracts and your NPI throughout.