Who we serve · Gastroenterology
Gastroenterology practices. Each scope billed for what it turned out to be.
HRI Med offers independent gastroenterology practices the full revenue cycle that Health Revenue Intelligence runs for behavioral-health facilities. We enroll the practice, every gastroenterologist, nurse practitioner and physician assistant, and the endoscopy center if you own one. Then we bill each procedure for what happened in the room: a screening, a screening that turned diagnostic, or a diagnostic study from the start.
Screening, the polyp, and where the scope happens.
A screening colonoscopy that finds a polyp becomes a different claim. For Medicare, the practice bills the diagnostic or therapeutic procedure with modifier PT instead of the screening code. The deductible stays waived, and the patient owes a reduced coinsurance that Medicare is phasing down to zero. Anesthesia turns with it, to a different code carrying the same modifier.A Patients remember that bill, so we make sure your front desk can explain it before the procedure.
Medicare also counts a colonoscopy that follows a positive stool-based test as screening. The claim carries the KX modifier, and neither test carries a deductible or coinsurance.A Commercial plans treat the same visit their own way, so we check each one.
Where the scope happens changes who bills what. In a Medicare-certified endoscopy center or a hospital outpatient department, Medicare pays the physician at the facility rate and the facility sends its own claim. In the office, the physician is paid the non-facility rate.B Payers watch that choice. UnitedHealthcare's commercial plans run a site-of-service medical necessity review when a screening colonoscopy is booked in an outpatient hospital, and encourage advance notification for diagnostic and surveillance colonoscopies, upper endoscopies and capsule studies.C
An endoscopy center the practice owns is its own Medicare supplier. As an ambulatory surgical center it needs its own agreement with CMS and must meet Medicare's conditions for coverage, shown through accreditation or a state survey.D It enrolls on its own application, the CMS-855B, apart from the physicians who work in it.E
The practice and the center, run as one file.
- Enrollment
- The practice and every gastroenterologist, NP and PA, with Medicare through PECOS, your state's Medicaid plans and the commercial plans on your list. An owned endoscopy center filed as its own supplier. Each application followed to an effective date.
- Procedure claims
- Screening, screening turned diagnostic, and diagnostic claims built to each payer's modifier rules, with the anesthesia claim coded to match when your practice bills it.
- Notifications and reviews
- Filed where a plan asks, with the site of service checked against the plan's review before booking.
- Denials
- Traced to the step that failed, whether a modifier, a notification or eligibility, and appealed where the practice is owed.
- The Friday board
- Where each application stands and, once billing starts, which procedure claims paid in full, paid short or came back denied.
| Piece of work | Fee |
|---|---|
| The practice, with each payer | $350 |
| Each gastroenterologist, NP or PA, with each payer | $250 |
| A clinician's CAQH ProView profile (CAQH now operates as DataSpring), built or repaired | $150 |
| Billing and revenue cycle | By agreement |
Total your own enrollment with the calculator.
Common questions from gastroenterology practices.
A screening colonoscopy found a polyp. What changes on the claim?
For Medicare, the procedure is billed as diagnostic or therapeutic with modifier PT, the deductible stays waived and a reduced coinsurance applies. Commercial plans each set their own rule, and we write it down for every plan on your list.
Do you enroll our endoscopy center?
Yes, as its own supplier with Medicare and with each commercial plan you name. Accreditation or the state survey stays the center's own work.
A new gastroenterologist joins soon. Where do we start?
One practitioner application with each payer at $250, plus $150 if the CAQH profile needs building. The plans most of your patients carry go first.
Sources
- CMS, Medicare Claims Processing Manual, chapter 18, sections 60.1.1 and 60.2. Read 2026.
- CMS, Medicare Claims Processing Manual, chapter 12, section 20.4.2, on the facility and office rates for the same scope. Read 2026.
- UnitedHealthcare, commercial prior authorization requirements, gastroenterology endoscopy. Read 2026.
- 42 CFR 416.2, 416.25 and 416.26. Read 2026.
- CMS, Medicare enrollment application CMS-855B. Read 2026.
Send us your payer list and where you scope.
Tell us the plans your patients carry and where procedures happen. We read that against your enrollment, with no patient information involved.
Mention any payer that asks for approval before a colonoscopy or an upper endoscopy.