Gastroenterology Billing Guidelines: Key Updates in 2024-25

If you have a Gastroenterology practice, you need to know these coding updates to avoid significant delays in claim processing.

Stay ahead of changes by updating your software, documenting correctly for compliance, and following prerequisites for frequently billed codes. Modifications of insurance requirements, from the introduction of new Current Procedural Terminology (CPT) codes to stricter audit requirements, directly impact reimbursement rates, claim processing, and compliance.

Stay on top of these crucial updates to keep your practice running smoothly and your reimbursements flowing without delay in 2024 and beyond.

1.  Procedure and Evaluation and Management Code Updates

The 2024 updates to CPT codes for gastroenterology reflect several key changes aimed at improving coding accuracy and reimbursement for GI procedures. These include additions and revisions that account for new technologies and refined procedural techniques.

1. New Technology Codes: CPT codes have been updated to reflect emerging GI technologies such as video capsule endoscopy. This includes both diagnostic and therapeutic uses with prerequisites that must be met to process claims.
2. Fecal Microbiota Transplant (FMT): There are specific codes for the preparation and instillation of fecal microbiota, such as 44705 and G0455 for Medicare claims. The code changes specify how to bill for donor specimen preparation and installation procedures​.
3. Evaluation and Management (E/M) Updates: Codes for outpatient services like 99202-99205 and 99212-99215 now feature revised time-based documentation, ensuring easier and more accurate billing based on the total time spent​.

2. Revised Codes for Capsule Endoscopy

Video Capsule Endoscopy (VCE) continues to play an important role in diagnosing conditions of the small intestine, such as obscure gastrointestinal bleeding, Crohn’s disease, and celiac disease. In 2024, there have been revisions to the CPT codes for capsule endoscopy to reflect advances in capsule technology and clinical usage.

• 91110 and 91111: The existing codes for capsule endoscopy (CPT 91110 and CPT 91111) have been updated to include clearer definitions and instructions for their use. These updates provide more specificity in coding, ensuring that practices can bill correctly based on the anatomic area examined and the interpretation of the results.
• New Codes for Extended Capsule Monitoring: In response to advancements in capsule technology, which now allows for extended monitoring beyond the typical 8-hour period, new CPT codes have been introduced. These codes allow gastroenterologists to bill for longer-duration capsule studies, particularly useful for patients with intermittent symptoms or for evaluating motility disorders.

3. Telemedicine Billing Guidelines for Gastroenterology

While telemedicine gained traction during the pandemic, its use in gastroenterology has evolved, particularly for follow-up care and initial consultations. In 2024, new telemedicine billing guidelines will enable practices to expand their virtual services while maintaining proper billing standards.

Key changes include:

• Expanded coverage for remote patient monitoring (RPM) in gastroenterology, especially for chronic conditions like Crohn’s disease and irritable bowel syndrome (IBS).
• Clearer coding for virtual consultations, especially when following up on procedures like colonoscopy or endoscopy.
• Adjustments in reimbursement rates for virtual visits, ensuring parity between in-person and telehealth services.

4. Modifier Updates for Gastroenterology Procedures

Along with new CPT codes, 2024 brings updates to several important modifiers used in gastroenterology billing. Proper use of these modifiers is essential to ensure that providers are fully reimbursed for the services they provide.

• Modifier -33 for Preventive Services: The guidelines for using modifier -33 (preventive services) have been updated to include more detailed instructions on when it should be applied to gastroenterology procedures like colonoscopy. This modifier ensures that patients are not billed for preventive screenings that are fully covered by insurance.
• Modifier -59 for Distinct Procedures: Modifier -59, used to indicate distinct procedural services, remains important for gastroenterology billing, especially when multiple procedures are performed on the same day. The 2024 updates include additional guidance on when this modifier should be used to avoid claim denials due to bundling.

5. Prior Authorization and Documentation Requirements

Prior authorizations have been a challenge for many practices. In 2024, gastroenterologists can expect more stringent prior authorization protocols, especially for advanced procedures like capsule endoscopy and certain therapeutic ERCPs.

To streamline approvals, practices will need to ensure:

• Comprehensive documentation: Payers now require detailed notes that reflect medical necessity, especially for elective and higher-cost procedures. For Capsule Endoscopy, call insurance to verify if you will need to submit both Colonoscopy and Endoscopy reports with your Capsule claims.
• Automation tools: The increased workload may necessitate the adoption of billing software that automates prior authorization requests and keeps track of status updates. But, when in doubt, please call insurance or use insurance portals for clarification and note down the call reference number or portal screenshot.

Failure to comply with these new protocols can delay reimbursements or result in outright denials, leading to revenue loss.

6. Updated National Correct Coding Initiative (NCCI) Edits

The NCCI edits continue to play a vital role in reducing improper coding and avoiding duplicate billing. The 2024 updates will see new code pair edits that directly impact gastroenterology procedures. In particular:

• Colonoscopy and polypectomy services will face updated edits, which will limit the billing of certain procedures in combination.
• Updates to the handling of modifier usage, especially for bundled services that are often billed together.

Gastroenterology practices must review the latest NCCI guidelines to avoid costly claim denials.

7. Increased Focus on Compliance and Audits

Compliance is becoming more critical as audits for gastroenterology practices increase in frequency and intensity. Payers are focusing on identifying and reducing fraud, waste, and abuse, making proper documentation and accurate coding more important than ever.

• Risk of audits: Practices performing a high volume of specific procedures like colonoscopies or advanced endoscopies may see a higher likelihood of being audited.
• Documentation standards: Practices must ensure that their records accurately reflect the services performed, especially when using modifiers or billing for complex cases.

Investing in compliance training for billing staff and regular internal audits is a smart move to stay ahead of potential pitfalls. Team up with an experienced billing team with a proven track record for GI billing. Choose a billing team that can help doctors code efficiently as well.

8. Reimbursement Rate Adjustments

The Centers for Medicare & Medicaid Services (CMS) has introduced adjustments to the Medicare Physician Fee Schedule (MPFS) for 2024. These changes will directly impact reimbursement rates for many gastroenterology services. Practices should pay attention to:

• Reduced reimbursement rates for certain endoscopy procedures. For commercial insurances, you should try to renegotiate for higher fees.
• Adjustments to the value-based care reimbursement model, particularly for practices participating in Alternative Payment Models (APMs).

While some services may see a decline in reimbursement, others, particularly those related to telemedicine and chronic care management, may benefit from higher rates.

Stay Informed on Gastroenterology Billing and Coding

The new CPT codes for gastroenterology in 2024 reflect the rapid advancements in diagnostic and therapeutic techniques within the field. From endoscopic innovations to remote monitoring and personalized biologic treatments, these updates ensure that gastroenterologists can provide cutting-edge care while being adequately compensated for their expertise.

Staying current with the latest CPT and ICD-10 codes is essential for maintaining compliance, reducing claim denials, and protecting revenue. As coding guidelines, payer policies, and reimbursement rules continue to evolve, having an experienced billing partner can make a measurable difference. FC Billing provides Gastroenterology Billing Services that help practices improve coding accuracy, streamline claims management, and optimize revenue cycle performance.