Denials in GI Coding—Where It Goes Wrong (and How to Get It Right the First Time)

Denials in GI Coding—Where It Goes Wrong (and How to Get It Right the First Time)

When it comes to GI procedures, getting paid correctly often comes down to details—not in the OR, but in the documentation.

Take a routine screening colonoscopy. If a polyp is discovered and removed, that shifts the procedure from preventive to therapeutic. Clinically, the change may seem minor. But from a commercial insurance or government payer’s standpoint, it carries weight—and can mean the difference between a clean claim and a denied one.

Understanding the Modifiers That Matter

If the documentation doesn’t clearly reflect that the service began as preventive, the claim may be denied—or the patient may receive an unexpected bill.

Here’s a quick reminder on key modifiers for these situations:

• Modifier PT is used for Medicare to indicate a screening procedure that became therapeutic
• Modifier 33 is used for commercial payers under ACA preventive care rules when the procedure becomes therapeutic
• Missing or misapplied modifiers can delay reimbursement or create billing confusion

These aren’t rare mistakes—they’re common, especially in fast-paced settings where documentation workflows vary and payer requirements change frequently. The result is often additional back-and-forth, delayed payment, and a frustrated patient or provider.

How Smart Technology Can Quietly Simplify the Process

Born from real-world workflows, this AI-powered claim-prep tool catches errors at precisely the moments they appear. Operating seamlessly in the background, it scans every claim for issues such as:

• ✔ Missing or inconsistent modifiers
• ✔ Documentation gaps
• ✔ Payer-specific billing requirements
• ✔ Claims that may be flagged or delayed

It’s designed to offer gentle prompts and helpful catches—giving your staff time to correct small issues before they become big ones. It doesn’t disrupt workflows or require a steep learning curve. It just helps ensure your documentation aligns with coding and reimbursement expectations across payers.

The Benefit? Simpler Billing. Smoother Days.

• Clean claims the first time
• Fewer denials
• Less time correcting mistakes
• More confidence in your revenue cycle

Your team is already doing the work. This tool simply helps make sure they get recognized—and reimbursed—for it.

Because the real focus should be the care, not the claims.

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Rusanne Baggett, RHIT | CHDA
Medical Writer | HIM Expert | Founder – Rusmi Consultation LLC | LinkedIn