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Gastroenterology: Managing Regulatory Tailwinds

In 2017, one healthcare investor said that "we are in the golden age of older rectums." Well into 2023, this quote continues to resound thanks to the high focus on preventing colorectal cancer, the second most common cause of cancer death in the US.
Beginning in 2023, CMS made important updates to the colorectal cancer screening (CRC) guidelines. In addition to lowering the minimum age for Medicare-covered CRC from 50 to 45, there was also an important change tied to a colonoscopy following a positive result from a non-invasive stool-based CRC test, such as Cologuard. Medicare ASC payments for colonoscopies with lesion removals and colonoscopies and biopsies are also expected to increase in 2023.
It is no surprise then that with these regulatory tailwinds, GI was the second most active specialty for M&A transactions in January 2023, accounting for roughly 10% of all physician medical group transactions.
Farragut has advised several GI platforms on how they can ensure optimal screening and that patients are not inappropriately billed due to a lack of understanding of these updates.
An area of confusion we see is when a screening colonoscopy gets converted to a diagnostic or therapeutic colonoscopy during a visit. The relevant modifier should be appended to codes that will waive the Medicare deductible or tell the payer that the main purpose of the test was screening—but this is often missed. With these codes being a significant percentage of a GI practice's revenue, it is important to get this nuance right.
Additionally, for a screening colonoscopy, billing an E/M visit when the patient is asymptomatic is not covered. But sometimes, we find this error in coding, and since the latter is of higher value, such charts are considered upcoded. With the increase in volumes for screening, gaps in awareness of such rules of coding can quickly snowball to outlier levels of over-coding at a practice and flag payers to investigate the root cause.
Colonoscopy utilization codes are among the top 5 billed codes at any busy GI practice. When was the last comprehensive external coding audit done to ensure your practice is up to date with the regulatory changes? Did the coders receive education related to the results of that audit?
In our external audits, we isolate issues and train staff to quickly and painlessly remediate gaps. We work with all sub-specialties of the gastrointestinal system, such as bariatric surgery, endocrinology, and hepatology. Our clients include some of the largest PE-owned platforms to founder-owned single-modality specialists.

Connect here to learn more about Farragut Square Group's expertise in GI audit and compliance consulting.

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