Category: Gastroenterology

13 Dec 2018

Private equity in gastroenterology: A train that’s left the station

Well, they are calling it the golden age of rectums! The trends are simple and straightforward.

First, baby boomers and beyond are aging and staying alive longer. The gut, a hidden culprit in many ailments, requires continuous maintenance. Colonoscopies. EGDs. Things that require services of gastroenterologists who are always in short supply (14,000 in the US).

Second, gastroenterology (GI) practices are fragmented like hotels were before Hilton. Regulatory, technological, insurance complexities are weighing GI doctors down. Frustrated with the burden of running practices, many doctors join hospitals. And discover that it’s difficult to survive under the thumbs of demanding hospital administrators.

Third, there’s plenty of new money in private equity ($453 billion in 2017). Healthcare, one of the biggest problems of our times, is attracting PE interest, albeit quietly. Unlike earlier decades when IPOs were the main forms of exits, PE companies can now find exits by selling rolled up portfolios to larger PE firms. Plus, PE firms follow each other around.

Fourth, specialties such as gastroenterology can indeed improve revenues by streamlining billing, negotiating insurance contracts, adding ancillary services, and building a strong management team. All of these are possible with consolidation and investments. Given that physician partners don’t usually align, a third-party facilitator such as PE firm would find it easy to disrupt and consolidate.

The question really isn’t about whether PE involvement would be right for gastroenterology or medicine as a whole.

It’s too late in the day to ask that question. The train has already left the station.

Consider these announcements.

  1. In 2016, Audax Group made major investments in both Urology and Gastroenterology.
  2. In 2017, KKR bought Covenant Surgical Partners from DFW Capital
  3. In 2017, Warbus Pincus bought CityMD, an urgent care chain
  4. In 2017, Harvest Partners bought Katzen Eye Group from Varsity Health Partners
  5. In 2016, ABRY Partners invested in US Dermatology Partners
  6. In 2017, Varsity invested in The Orthopedic Institute
  7. In 2016, Sverica Capital acquired RMS Healthcare Management, a primary care provider
  8. In 2017, New Mainstream Capital acquired Cordental Group, a dental chain

The article lists more deals in behavioral health, hospice, women’s health, ER and so on.


Given my company’s business, I’m particularly plugged into gastroenterology. At a recent GI conference, we noticed that one of the newly consolidated super groups even had a booth. I met physician-owners who were exhibiting at the conference so that they could court other doctors and eventually buy them out.

What was more interesting is that they were looking for sophisticated technology solutions. And were considering experimenting with computer vision to detect polyps (finding polyps is something that GI doctors routinely do via colonoscopy).

Read: Artificial Intelligence-Assisted Polyp Detection for Colonoscopy: Initial Experience

Naturally, I wondered what it’s like for a doctor to work in a PE-run organization versus a hospital. Like with any large organization, the super groups were run by small boards and a CEO. Firm decisions were made by the board. A larger (“rubber stamp”) board passed the rules further down. These decisions were rolled out to the army of doctors across the organization.

Someone I chatted with said, “The pros were that they had better insurance contracts.” And cons, I asked quickly? He shrugged, “Well, they will eventually get their way!”

Plenty of mid-sized GI groups I spoke to were still wondering what to do. Expand by merging with other groups? Sell-out to a hospital? Be found by a PE firm that’s eager to consolidate? Wait and watch?

I found examples under all models.

A group we work with has been consolidating regionally by acquiring solo and other mid-sized GI groups. A potential client whom we never got around to working with sold out to the local hospital that wanted to create a “state of the art” gastroenterology department. Some others entertained PE conversations across several GI groups only to discover in the end that all talks collapsed. Because the partners wouldn’t see eye to eye. Many others were watching from the side lines.

If you amplify these signals, you’ll surely hear the songs of consolidation.

It’s warming up. The ice is melting. A little quickly now. New rules are forming. No one knows what exactly those rules are. But they are forming anyways. And when they form, the lake will start freezing. Again. To stay frozen for a long time.


1) Provident Perspectives: Private Equity Investment in Gastroenterology

2) How to look at private equity investment in physician groups: Gastroenterology

3) Hot physician specialties for private equity investment

4) Physician and Private Equity Partnership: Goal is to Create Larger, More Robust Platform for Delivery of Care

5) Where Health and Investment Collide: Health Care Private Equity Trends to Watch in 2018

6) Medical practices have become a hot investment — are profits being put ahead of patients?


Originally published on LinkedIn,  by Praveen Suthrum, President & Co-Founder, NextServices. 

27 Sep 2018

NextServices to Showcase The Gastro Suite at the American College of Gastroenterology 2018

The Gastro Suite is an all-in-one software and services platform for gastroenterologists. It combines gastroenterology billing, coding, EHR, endoscopy report writer and MACRA consulting.
– Ann Arbor, MICH. (PRWEB) September 26, 2018

NextServices will be showcasing The Gastro Suite at the American College of Gastroenterology (ACG) 2018. The Gastro Suite is a state-of-the-art platform that comprehensively addresses administrative, technological and compliance challenges of gastroenterology groups.

“Unpredictable income. Old software. Endless mandates. Rising costs. Gastroenterologists are running faster than ever to stay in the same place. It’s time to think differently,” said Praveen Suthrum, President and Cofounder, NextServices. He added, “Through a unified software and services platform, The Gastro Suite makes these problems go away.”

The Gastro Suite integrates:

GI billing/revenue cycle management: Improve efficiency and revenues through end-to-end revenue cycle management. Services includes credentialing, authorizations, payor setups, surgery center, practice and hospital claims submission, denial management, insurance and AR management. Cloud-based practice management software included as needed.

GI coding: Protect from audit risks, bill more accurately and save coding expenses. Certified coders streamline E&M and procedure coding on an ongoing basis.

enki EHR: Certified, cloud-based gastroenterology EHR that is refreshing and remarkably easy to use.

enki Endoscopy Report Writer: GIQuIC certified, cloud-based endoscopy report writer that saves time and money. Includes free future upgrades.

All enki software products come with a 60-day money back guarantee.

MACRA consulting: MACRA/MIPS advisory services that include compliance training, tracking, unlimited support and data submission to registries to avoid negative payment adjustments.

“We’ve seen the gastroenterology landscape change over the last 14 years. Reimbursements have dropped. Costs have risen. And there’s increased regulation to deal with,” said Satish Malnaik, CEO and Cofounder, NextServices. He added, “Partner with us to not just navigate but thrive in this uncertain environment.”

Attendees can learn more about The Gastro Suite at ACG 2018 during October 7-9th, 2018 in Philadelphia, PA. NextServices will be exhibiting at booth #511.


About NextServices

NextServices provides cloud based billing and software platform that gastroenterology practices need to thrive in an environment of tougher reimbursements, high operating costs and increased regulation. Our solutions include – billing and coding services, enki EHR platform, enki Endoscopy Report Writer and MACRA/MIPS consulting. For more information contact (734) 677 7730 or visit the company’s website at

About American College of Gastroenterology (ACG)

The American College of Gastroenterology (ACG) is a recognized leader in educating GI professionals and the general public about digestive disorders. Our mission is to advance world-class care for patients with gastrointestinal disorders through excellence, innovation and advocacy in the areas of scientific investigation, education, prevention, and treatment. To learn more about ACG, visit


02 May 2017

Fecal microbiota transplant: Procedure and coding guidelines

Fecal Transplant - Procedure and coding guidelines1

Fecal transplantation is a procedure performed for patients suffering from recurrent infections by a type of bacteria called Clostridium difficile. The infection is spread through contact with surfaces contaminated by spores of the bacterium. The range of symptoms include diarrhea, pseudomembranous colitis, fever, nausea and abdominal pain.

In recent times, there has been an increased antibiotic resistance for C. difficile. Fecal bacteriotherapy or stool transplant is an emerging technique for treating patients suffering from such antibiotic resistance.

The procedure
Fecal microbiota transplant (FMT) involves transplantation of fecal microbiota collected from a healthy individual into the gut of patient. The donor’s stool sample is carefully screened and selected for transplant.

A close relative may prove to be suitable donor however, non relatives stool samples may also be effective.

Fresh stools are often used for preparation of an infusion. Once ready, the infusion is administered by means of enema using a colonoscope or through a nasogastric tube.

Indications for the therapy
• Clostridium difficile infection

Coding guidelines

For Medicare:
CPT code to be reported – G0455 – Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen

(Medicare does not pay a separate fee for the installation of the microbiota by oro-nasogastric tube, enema, or by upper or lower endoscopy)

ICD-10 codes that can be reported:

Z20.9 – Contact with and (suspected) exposure to unspecified communicable disease

Z22.1 – Carrier of other intestinal infectious diseases

Z11.59 – Encounter for screening for other viral diseases

Z11.3 – Encounter for screening for infections with a predominantly sexual mode of transmission

Z11.2 – Encounter for screening for other bacterial diseases

Z11.0 – Encounter for screening for intestinal infectious diseases

Z11.8 – Encounter for screening for other infectious and parasitic diseases

Z11.9 – Encounter for screening for infectious and parasitic diseases, unspecified

For commercial payors:
44705 – Preparation of fecal microbiota for instillation, including assessment of donor specimen
44799 – Fecal instillation by oro-nasogastric tube or enema (This CPT code is used to indicate  instillation).

Do not report 44705 in conjunction with 74283 (Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (e.g., meconium ileus)

Have a coding question? Let me know in the comments below.

The information is presented for educational use only. It is not meant to be used to diagnose or treat any medical condition. We have made all reasonable efforts to ensure the information provided in this guide is accurate at the time of inclusion, however, please resort to clinical documentation and your experience to make decisions while coding and billing for procedures.

By Sandeep Paranjape, NextServices

07 Mar 2017



Remembering codes with so many permutations and combinations can be really overwhelming. To help you understand and code better, we have created this reference guide which you can refer to code and bill accurately for your next case. Guide includes CPT Codes for Colonoscopy, Esophagoscopy, EGD, Enteroscopy, ERC and Sigmoidoscopy.




October 1st, 2016 marked the end of the grace period allotted by CMS and AMA to facilitate smooth ICD-10
implementation. During the grace period, insurances processed claims even if they were wrongly coded, just as
long as the codes belonged to the broader family of correct codes. However, such claims will not be paid after
the grace period. It now becomes crucial for medical practices to strictly adhere to ICD-10 coding guidelines to
avoid payment disruptions.

Guide includes ICD-10 Coding guidelines for screening and surveillance colonoscopy.





Disclaimer – The information is presented for educational use only. It is not meant to be used to diagnose or treat any medical condition. We have made all reasonable efforts to ensure the information provided in these guides are accurate at the time of inclusion, however, please resort to clinical documentation and your experience to make decisions while coding and billing for procedures.

18 Feb 2017

How to code for ulcers according to ICD-10 guidelines

With ICD-10, reporting for type, occurrence site, and complication has dramatically increased coding complexity. There are codes ranging from problems in relationship with in-laws (Z63.1) to being pecked by a chicken (W61.33) to being bitten by a sea lion (W56.11)!

Ulcer is one of the most frequently reported diagnosis codes in gastroenterology. However, with the advent of ICD-10, coding for the simple diagnosis has become complicated for even the most experienced doctors.

To make your life a little easier, we compiled a list of accurate coding guidelines for ulcers that you could refer to for your next case.

Ulcers are broadly classified based on the organ they are present.

1) Gastric ulcer (K25)

2) Duodenal ulcer (K26)

3) Peptic ulcer (K27)

4) Gastrojejunal ulcer (K28)

Each type of ulcer is further classified into acute or chronic. If the nature of ulcer cannot be determined, an “unspecified” code may be used.

Coding now goes up to the 4th level (or the fourth digit of ICD-10 code) of specificity. Each type of ulcer is coded with reference to the complications associated with it. For example, the code used for Acute gastric ulcer with hemorrhage would be K25.0

The ICD-10 CM manual also instructs the use additional codes if the patient is diagnosed with alcohol abuse and dependence.

F10 is the ICD-10 code for alcohol related disorders which is classified further into alcohol abuse (F10.1), alcohol dependence (F10.2), alcohol use, unspecified (F10.9). The F10 code can be further specified by the use additional codes. For example, blood alcohol level measurement is Y90.

Let’s understand this using a patient scenario:

Joan, age 36 years, presented with abdominal pain, nausea, vomiting and melena. She was scheduled for EGD after unsatisfactory PPI treatment. EGD revealed acute duodenal ulcer which was bleeding along with perforations. She consumes alcohol every day and shows withdrawal delirium. Her blood alcohol levels were 72 mg/100ml.

The coding for this scenario would be as follows:

Primary code: K26.2 (because the type of ulcer is duodenal and it is acute with hemorrhage and perforation)
Secondary code: F10.231 (because she exhibits alcohol dependence with withdrawal delirium)
Tertiary code: Y90.3 (because of the range of her blood alcohol level is 60-79 mg/100 ml)

This is how you think in an ICD-10 world. More specifically.

Below are coding guidelines in a tabulated format:

How to use this table:

The (*) mark specifies the nature of the condition.

For example, if an ulcer is duodenal, is acute and hemorrhage is present – the code to use would be K26.0

Another example, if an ulcer is peptic, is chronic/unspecified and hemorrhage is present – the code to use would be K26.4

Correct coding practices are the backbone for clean claims. Submitting clean claims with high first-pass ratio bring predictability in reimbursements. Pay attention to the levels of specificity that ICD-10 demands.

Have you come across any unique coding scenarios? Let me know in the comments below.


By Sandeep Paranjape, NextServices


[FREE GUIDE] How to bill accurate codes for endoscopy procedures

Adhere to ICD-10 coding guidelines now [avoid payment disruptions]


20 Dec 2016

Product and Feature Launches in 2016

Major enki features and products launched in 2016.



enki Telemedicine
enki Telemedicine module lets you seamlessly connect to your patients wherever they are. Enable remote healthcare delivery in a secure and simple way using video and messaging based consults.



enki Patient Portal

The new and improved version of enki Patient Portal allows patients a convenient access to their medical records 24×7. The patient portal also integrates enki Telemedicine modules for virtual consults. Patients can interact with you, request appointments and medication refills directly through secure messaging modules.


enki EndoWriter helps you capture endoscopy images and document your procedures effortlessly. Cloud based technology frees you up from expensive hardware and provides access to your notes from anywhere. One platform integration with enki EHR greatly improves your efficiency.




ICD-10 integration

enki EHR demonstrates complete ICD-10 integration across all clinical documentation modules. The simplified ICD-10 code selection interface guides you to the accurate diagnosis code for documenting your cases in a structured and compliant way.





21 Jul 2016

Adhere to ICD-10 Coding Guidelines Now [avoid payment disruptions]

October 1st, 2016 marks the end of the grace period allotted by CMS and AMA to facilitate smooth ICD-10 implementation. During the grace period, insurances processed claims even if they were wrongly coded, just as long as the codes belonged to the broader family of correct codes. However, such claims will not be paid after the grace period. It now becomes crucial for medical practices to strictly adhere to ICD-10 coding guidelines to avoid payment disruptions.

Here are a few guidelines for screening and surveillance colonoscopy.

Difference between screening and surveillance colonoscopies
Screening is a test provided to a patient in the absence of signs or symptoms. A screening colonoscopy is a service performed on an asymptomatic person for the purpose of testing the presence of colorectal cancer or colorectal polyps.
A surveillance colonoscopy can be performed at varying ages and intervals based on the patient’s personal history of colon cancer, polyps, and/or gastrointestinal disease. For example, patients with a history of colon polyps are not recommended for a screening colonoscopy, but for a surveillance colonoscopy.

Coding guidelines
ICD-10 guidelines clearly demarcate between coding for screening and surveillance.

Screening for malignant neoplasm of  ICD-10 code
Stomach Z12.0
Intestinal tract, unspecified Z12.10
Colon Z12.11
Rectum Z12.12
Small intestine Z12.13
Other sites Z12.89
Site unspecified Z12.9
Non cancerous disorders ICD-10 code
Screening for upper GI disorder Z13.810
Screening for lower GI disorder Z13.811
Screening for other digestive disorders Z13.818


Additional codes for family history of malignant neoplasm

Z80.0 –   Family history of malignant neoplasm of digestive organs

Z83.71 – Family history of colonic polyps

Z83.79 – Family history of other diseases of the digestive system


Surveillance colonoscopy codes

Z08 – Encounter for follow up examination after completed treatment of malignant neoplasm.
Use additional code for personal history of malignant neoplasm (Z85.-)

Organ Malignancy ICD-10 Code
Stomach Carcinoid tumor Z85.020
Other malignant neoplasm Z85.028
Large intestine Carcinoid tumor Z85.030
Other malignant neoplasm Z85.038
Rectum, rectosigmoid junction, anus Carcinoid tumor Z85.040
Other malignant neoplasm Z85.048
Liver Malignant neoplasm Z85.05
Small intestine Carcinoid tumor Z85.060
Other malignant neoplasm Z85.068
Pancreas Malignant neoplasm Z85.07
Other digestive organs Malignant neoplasm Z85.09

Z09 – Encounter for follow up examination after completed treatment for conditions other than malignant neoplasm.

[Read: Choosing between Modifier 53 and 52 – Gastroenterology example]

Additional codes to identify any applicable history of diseases (Z86.-, Z87.-)

Z86.010 – Personal history of colonic polyps
Z86.012 – Personal history of benign carcinoid tumor
Z86.018 – Personal history of other benign neoplasm
Z86.03 – Personal history of neoplasm of uncertain behavior
Z86.19 – Personal history of other infectious and parasitic diseases.
Z87.11 – Personal history of peptic ulcer disease
Z87.19 – Personal history of other diseases of digestive system

Colonoscopies account for majority of a gastroenterologist’s revenues. It’s important that doctors and their coders pay close attention to the specificity that ICD-10 demands. Systems like enki EHR help in directing doctors to code correctly at the point of care.


[FREE GUIDE] How to bill accurate codes for endoscopy procedures

How to code for ulcers according to ICD-10 guidelines

09 Apr 2016

Our latest updates on Becker’s ASC


1. NextServices Showcases Solutions at Digestive Disease Week 2014
(GI Endoscopy-Driven Surgery Centers to Know 2013) NextServices announces endoscope integration with enki EHR at DDW 2014.
2. How Do GI Coding Changes Affect the Field? Reimbursement, Technology, Denials & More 
(ASC Coding, Billing and Collections) Praveen Suthrum, president and co-founder of NextServices, explains what the 2014 changes mean for gastroenterologists and GI-driven ambulatory surgery centers.
3. How to Boost Clean Claims Submission at ASCs 
(ASC Coding, Billing and Collections)Nextservices blog post outlined on how ambulatory surgery centers can achieve 95 percent clean claims submission ratio.

4. Sending Patient Statements: Tips From NextServices 
(News & Analysis) In a recent blog, NextServices provided the most effective methods for sending patient statements in order to see results.
5. 11 Esophagoscopy Code Updates to Know 
(ASC Coding, Billing and Collections) Gastroenterology coding changes.
6. Collect From Patients: Best Practice for Sending Statements 
(News & Analysis)NextServices recently posted an article about sending patient statements on their blog. The article discusses whether providers should send patient statements daily or in bulk.
7. NextServices Exhibits EHR Through Google Glass 
(News & Analysis) NextServices announced it has unveiled the prototype for enki Glassware at FutureMed in San Diego.
8. Futuristic Healthcare: 7 Considerations for Ambulatory Surgery Centers 
(ASC Turnarounds: Ideas to Improve Performance) Praveen Suthrum, president and co-founder of NextServices provides a look ahead for ambulatory surgery centers.

09 Apr 2016

What does it mean that 25% of ALL coding changes are related to Gastroenterology?


American Medical Association (AMA) added 175 new codes, revised 107 CPT/ procedure codes this year – 25% of them are related to gastroenterology (26 new codes, 41 revised codes and 17 deleted codes). Let’s consider an example.

If a patient showed up with a tumor in her esophagus, a gastroenterologist typically performs an esophagoscopy using snare technique to remove the tumor. A new technique has been doing the rounds during the past few years called Endoscopic Mucosal Resection (EMR) – it uses a suction mechanism to yank the tumor out from the skin before it’s cut. The technique helps in controlling unnecessary bleeding. Up until this year, EMR had no code. But this year, AMA recognized it with  43211 – a new code.

Up until this year, it didn’t matter whether a gastroenterologist used a flexible/ rigid scope or went in through the nose/ mouth during an esophagoscopy. But with the coding changes, it matters now – there’s increasing specificity.

What do examples of such coding additions/ changes mean for gastroenterology? At a very broad level, it simply means that there’s a shift underway. The patients are the same, the disease conditions are similar but how something can be diagnosed and treated is actively undergoing a change. Ambulatory surgery centers consider traditional upper and lower GI procedures as their bread and butter. But with steady innovation, better understanding and wider spread of newer techniques, the specialty will become even more specialized. Traditional procedures will continue to see declining reimbursements.

Knowing what we know of medicine, as procedures become mainstream, reimbursements decline and newer techniques become the preferred approach. It may be entirely possible that EMR may replace traditional esophagoscopy in the future. What if enough artificial intelligence algorithms may be built in to identify polyps from a video produced by a Video Capsule Endoscopy? What if the algorithms identify all possible polyps big and small throughout the digestive tract? Such thorough and extreme accuracy would be impossible with traditional colonoscopy that involves human hands and eyes. What would happen then to doctors who are not used to learning or experimenting with new procedures?

It’s also expected that in 2015, there would be lower gastroenterology coding changes. These coding changes are simply an acceptance of newer methods to treat and fix conditions and also a gentle nudge to gastroenterologists to stay current in their fields.

By Praveen Suthrum, President & Co-Founder, NextServices

09 Apr 2016

Esophagoscopy coding changes in 2014


Upper gastroenterology coding has seen important changes since Jan 1, 2014 – particularly, esophogoscopy procedures. Separate codes have been introduced for rigid esophagoscopy and flexible esophagoscopy.

Six new procedure codes have made an entry for rigid esophagoscopy this year. However, these codes are to be used only when esophagoscopy is done via the transoral route. In 2013, there were no separate codes for rigid transoral esophagoscopy – rigid or flexible esophagoscopy were included under the same definitions. In 2014, the specificity has increased based on the route of administration of scope i.e., transoral or transnasal and on whether the scope used was flexible or rigid.

If a rigid scope was used, the following new codes may be applied for the transoral route:

43191 – Rigid transoral e1sophagoscopy, diagnostic, brushing and washing. By using rigid scopes, procedures such as submucosal injections, biopsy, foreign body removal, balloon dilation, guide wire insertion and dilation over guide wire can be performed. CPT codes from 43192 through 43196 have been created to be used for these procedures.

If a flexible scope is used, but the route of administration is transnasal, these codes may be used:

43197 – Flexible transnasal esophagoscopy, diagnostic, brushing washing.

43198 – Flexible transnasal esophagoscopy, with biopsy.

Certain terminologies with respect to esophagoscopy have been revised. For e.g. CPT code 43200 is defined as ‘flexible’ (in 2014) as against ‘rigid or flexible’ (in 2013). CPT codes from 43200 through 43232 are now termed as flexible. The other specifications of the code descriptor remain the same.

New codes for Flexible Transoral Esophagoscopy

43211 – Flexible transoral esophagoscopy, mucosal resection. Till 2014, esophageal mucosal resection was reported by using unlisted codes 43499 (unlisted procedure, esophagus).

43212 – Flexible transoral esophagoscopy, stent placement, dilation and guide wire passage.

A new concept has been introduced, flexible transoral esophagoscopy with retrograde dilation with CPT code 43213.

43214 – Flexible transoral esophagoscopy, balloon dilation, including imaging. The imaging has been included effective 2014. Till 2014, imaging if performed had to be separately reported.

43229 – Flexible transoral esophagoscopy, with ablation, dilation and guide wire passage. This code now includes balloon dilation (43220), insertion of guide wire (43226) and ablation (43228).

By Sandeep Paranjape, Clinical and Coding expert, NextServices

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