Do you use Athenahealth for gastroenterology billing? Are you facing claim denials? Are you facing payment delays? Studies show a problem. About 35% of GI practices struggle with EHR billing. Athenahealth users report high denial rates at first. The denial rates are 25% higher initially. About 70% of practices face integration challenges. This happens in the first year. Wrong procedure codes cost GI practices money.
Athenahealth is a popular system. It is cloud-based. It is a practice management system. Many gastroenterology practices use it. They use it for billing. They use it for scheduling. The platform offers robust features. But it has learning curves. GI-specific procedures need special coding. They need special documentation always. Research shows something important.
This guide covers the biggest Athenahealth billing challenges. We show solutions. These solutions are specific to gastroenterology practices today. Learn how to optimize your system. This will give you better results. You can improve claim acceptance rates. You can reduce denials significantly. These tips help practices. They help maximize Athenahealth benefits fully. Follow these guidelines to get paid faster.
System Setup and Configuration Issues
Poor initial setup causes many billing problems. GI-specific templates need proper configuration always.
Incorrect Fee Schedule Setup
Athenahealth needs accurate fee schedules loaded first. GI procedure codes must match payer contracts. Update fees when insurance rates change annually. Missing or wrong fees cause claim rejections. Import fee schedules from payer portals regularly. Verify all CPT codes have assigned fees.
Template Configuration Problems
Default templates do not fit GI workflows. Create custom templates for endoscopy procedures specifically. Include all required documentation fields for compliance. Set up auto-population of common findings. Configure pathology integration for biopsy results properly.
User Permission Settings
Staff need appropriate access levels for roles. Billing staff need different permissions than clinical staff. Too many users with admin rights causes problems. Set up role-based access controls properly first. Limit who can modify fee schedules. Track all system changes with audit logs.
Procedure Coding Challenges
GI procedures use complex CPT coding rules. Athenahealth does not always catch coding errors. Understanding GI-specific codes prevents claim denials.
Endoscopy Coding Errors
Code 43235 covers upper GI endoscopy diagnostic. Code 45378 is a colonoscopy diagnostic base code. Add-on codes needed for biopsies and polypectomies. Multiple polyp removals need careful code selection. Base code plus highest level add-on first. Additional polyps use different add-on codes.
Modifier Usage Mistakes
Modifier 59 shows a distinct procedural service performed. Required for multiple procedures same session often. Modifier 25 indicates a significant separate E/M service. Use when office visit precedes same-day procedure. Modifier 76 shows repeat procedure same physician. Athenahealth may not prompt for modifiers.
Bundling and Unbundling Issues
Some GI procedures are bundled automatically by CCI. Cannot bill diagnostic and therapeutic colonoscopy together. Biopsy codes bundle into polypectomy codes sometimes. Athenahealth edits may miss some bundling. Use the NCCI edits checker before submitting. Override bundling only with proper modifiers shown.
Documentation and Compliance Problems
Incomplete docs cause 40% of GI claim denials. Athenahealth templates must capture all required elements.
Incomplete Procedure Notes
Document indication for procedure with ICD codes. Include prep quality for colonoscopy procedures always. Note the depth of insertion and withdrawal time. Describe all findings with specific locations noted. Document all interventions performed during the procedure completely.
Missing Medical Necessity Documentation
Every GI procedure needs a clear medical necessity. Document patient symptoms. These symptoms led to the procedure order. Include relevant family history. Include risk factors. Note failed conservative treatments. These treatments were tried previously. Explain why the procedure was appropriate at the time.
Pathology Integration Gaps
Athenahealth may not integrate with all labs. Manual entry of pathology results takes time. Missing pathology reports delay final billing. This happens sometimes. Set up automated lab result import when possible. Create alerts for missing pathology. This is for procedures. Bill pathology interpretation separately.
Insurance Verification and Authorization
Many GI procedures need prior authorization from insurance. Athenahealth verification tools have limitations sometimes.
Eligibility Verification Failures
Athenahealth checks eligibility automatically for appointments scheduled. Real-time verification is not always accurate or current. Copay amounts may differ from actual benefits. Deductible balances update with lag time delays. Always verify manually for high-cost procedures planned.
Prior Authorization Tracking
Colonoscopy and EGD often need prior auth. Athenahealth tracks auths but needs manual entry. Set up tasks for auth follow-up tracking. Enter the auth numbers in the system immediately received. Track auth expiration dates on the office calendar. Renew auths before they expire to avoid gaps.
Benefits and Coverage Issues
GI screening vs diagnostic have different coverage rules. Age requirements affect colonoscopy screening coverage limits. Frequency limits control how often procedures are allowed. High-deductible plans affect patient financial responsibility significantly. Verify specific procedure coverage before scheduling patients.
Claim Submission and Follow-Up
Timely claim submission is critical for revenue. Athenahealth automates submission but needs monitoring. Regular follow-up prevents payment delays and denials.
Claim Scrubbing Errors
Athenahealth scrubs claims before submission automatically daily. The system may miss GI-specific coding errors sometimes. Claims hold in the queue for manual review. Staff must review held claims daily without fail. Fix errors and resubmit claims promptly, same day. Track claim submission success rates by payer monthly.
Denial Management Workflow
Athenahealth flags denied claims for staff review. Sort denials by reason code for efficiency. Work highest dollar denials first for revenue. Appeal denials within payer timeframes are always strictly enforced. Track appeal success rates by denial reason. Identify patterns in denials for prevention steps.
Payment Posting Delays
ERA files post automatically in the Athenahealth system. Manual payments need staff entry and review. Payment posting lag affects AR reports accuracy. Post payments daily for accurate financial reporting. Reconcile bank deposits to posted payments weekly. Research unposted payments quickly to prevent aging.
Conclusion
Athenahealth billing challenges affect many GI practices. They affect them significantly today. System setup errors cause ongoing problems. Configuration errors cause ongoing problems. GI procedure coding requires specialized knowledge. It requires careful attention. Documentation gaps lead to denials. They lead to compliance risks. Prior authorization failures delay payments. Verification failures delay revenue.
FAQs
What is the biggest Athenahealth billing challenge for GI?
Incorrect procedure coding for endoscopy services causes most denials. GI procedures have complex coding rules. They have complex modifiers. Staff need specialized training. They need training on colonoscopy codes.
How can I reduce denials in Athenahealth?
Improve system setup. Use accurate fee schedules. Load them properly. Create GI-specific templates. Include all required fields. Train staff monthly. Train them on coding rules.
Does Athenahealth automatically check for bundling?
The system has some built-in edits. But it misses GI-specific rules. Manual review is needed before submitting complex procedure claims.
How do I set up prior auth tracking?
Enterthe auth numbers in the designated Athenahealth fields. Do this immediately. Create tasks for the auth expiration date follow-up. These are reminders. Set up reports showing procedures.
Can Athenahealth integrate with pathology labs?
Some labs integrate directly. They have automatic result import. Others require manual entry. They require manual entry of pathology reports.
How often should I audit my billing?
Monthly audits of fee schedules are recommended. Monthly audits of claim denials are recommended. A quarterly review of templates is needed. A quarterly review of documentation completeness is needed.
What reports should I run monthly?
Run denial reports by reason code. Run them by the payer company. Check days in AR aging. Check by payer. Check by procedure. Review claim submission success rates.
