Urology Coding and Reimbursement Podcast

August 4, 2023 

Ray, Mark, and Scott discuss 3 questions that came into the Urology Coding and Reimbursement Group (see below for link to sign up free).

1. Thank you for your recent podcast 147 with attention to updated Urocuff billing.  The recent change from our MAC NGS was helpful as this went into effect June 1, 2023 and they are now recommending billing 55899 as opposed to 51728-52. My question specifically relates to how to bill Medicare Advantage plans.  Do we follow the private payor rules that manage the plan or the MAC recommendation. For example, commercial payor A prefers the urocuff claim submitted as 51728-52.  If the Medicare advantage plan is administered through commercial payor A and we still have to follow their rules regarding prior authorization, utilization of specialty pharmacy for Botox rather than buy/bill for traditional Medicare, etc... It would seem that the urocuff in this case should be billed how we would bill the private payor using 51728-52 vs 55899. Any insight on this would be appreciated.
2. I am new to urology coding and Medicare rules. We have had a couple of patients admitted to the hospital during a surgical global period. These admissions are not related to the surgery. I coded the e/m code with a 24 modifier, but they were denied. Any help would be appreciated on how to get these claims to process.
3.  if our urologists, in the hospital setting, perform a procedure (ex. Ureteroscopy) and also they themselves administer the moderate sedation, are there additional CPT codes they can bill for?  If so, what are those codes?  the cpt book in the anesthesia guidelines seem to indicate that perhaps cpt codes 99151  99152 99153 may be coded to show this?  thank you

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July 28, 2023 

Ray, Mark, and Scott discuss staff shortages.  Mark shares insights on some of the things you can do to address the issue. 

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July 21, 2023 

Ray and Scott welcome special guest Marianne Desciose, Director of Operations for PRS Managed Services, LLC., to discuss Prior Authorizations and Prior Authorization Denials.

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Las Vegas, December 1 & 2, 2023
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

New Orleans, January 26 & 27, 2024
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

Reserve your spot and save!

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Use code: 24UACRS733

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The Thriving Urology Practice Facebook group.

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July 14, 2023 

Mark, Ray, and Scott discuss the newly released 2024 CMS Proposed Rules.  Mark provides a preliminary analysis of what changes are important to urology.

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Las Vegas, December 1 & 2, 2023
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

New Orleans, January 26 & 27, 2024
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

Reserve your spot and save!

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Use code: 24UACRS733

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The Thriving Urology Practice Facebook group.

The Thriving Urology Practice Facebook Group link to join:

https://www.facebook.com/groups/ThrivingPractice/ 

Join the discussion:

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 July 7, 2023 

Mark, Ray, and Scott discuss the problem section of E/M medical decision making.  The following question was asked that sparked this discussion:

Undiagnosed new problem with uncertain prognosis: When does a problem go from being new to chronic? For example, patient has an elevated PSA at their new patient appointment (new problem), some tests are ordered, then they follow up in one month. Could we use "undiagnosed new problem" again since we are still trying to diagnose and figure out what's going on? Or is it no longer a new problem because we have seen the patient before?

Inspired

Comment

Urology Documentation, Coding, and Billing Certification

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Documentation, Coding, and Billing Fellowship - Urology (DCB-FS)

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Documentation, Coding, and Billing Specialist Certification (DCB-SC)
Documentation, Coding, and Billing Master Certification (DCB-MC)

Urology Advanced Coding and Reimbursement Seminar

Click Here to Register Now  

Las Vegas, December 1 & 2, 2023
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

New Orleans, January 26 & 27, 2024
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

Reserve your spot and save!

As a Urology Coding and Reimbursement Podcast listener, you get access to a discount (limited-time offer).

Use code: 24UACRS733

Get signed up today and get peace of mind knowing you will be prepared for all the upcoming changes.

The Thriving Urology Practice Facebook group.

The Thriving Urology Practice Facebook Group link to join:

https://www.facebook.com/groups/ThrivingPractice/ 

Join the discussion:

Urology Coding and Reimbursement Group - Join for free and ask your questions, and share your wisdom.

Click Here to Start Your Free Trial of AUACodingToday.com 

June 30, 2023 

Mark, Ray, and Scott welcome back John Lin to answer more questions that have come into the Thriving Urology Practice Facebook Group. 

1. My billers are now getting a sh*t ton of denials of 99214 billed with modifier 25. Our documentation is correct. We have sent in OV notes and appealed and the insurance companies still deny. Most of the denials are coming from Anthem but some from Cigna.
   
   We are taking it to the next level of appeals and involving the "patient advocate" for the insurer, but I'm not sure what else to do.
   
   This is maddening and I'm sure they're just hoping we give up, but I KNOW (because of John C Lin) that they need to pay me for these appropriately coded E&Ms!!
   
   Anyone else seeing this? What else can be done?
   
   
2. 52332
   52235 51
   It was denied for unbundling.
   
   NCCI Edits show that this can be billed with a modifier.
   
   My CPT shows that we can bill 52332 with another procedure with Modifier 51
   
   52332 was done due to tumors overlying area of left ureteral orifice.
   
   Has anyone else had trouble billing these two codes together.
   
   Payer: Centene Ambetter, a Marketplace plan that pays better than Medicare.

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Documentation, Coding, and Billing Fellowship - Urology (DCB-FS)

 For Coders, Billers, and Admins
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Documentation, Coding, and Billing Specialist Certification (DCB-SC)
Documentation, Coding, and Billing Master Certification (DCB-MC)

Urology Advanced Coding and Reimbursement Seminar

Click Here to Register Now  

Las Vegas, December 1 & 2, 2023
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

New Orleans, January 26 & 27, 2024
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

Reserve your spot and save!

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Use code: 24UACRS733

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Dr. Lin is the administrator of The Thriving Urology Practice Facebook group.

The Thriving Urology Practice Facebook Group link to join:

https://www.facebook.com/groups/ThrivingPractice/ 

Join the discussion:

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 June 23, 2023 

Mark, Ray, and Scott welcome back Larry Kemp, FACHE to continue the discussion on Integrated Practice Wide RCM.  In part 2 of this 4-part series, Larry shares information about Point of Service Actions.

Key Points of Action:

• Sustaining practice RCM metrics.
• Understanding basic billing and collections actions
• Implementing performance improvement change – Theory versus effective application
• Often practices are missing far too much uncollected reimbursements. Why? Due to poor business practices that cause RCM leaks. These are preventable.
• Every missed pre-authorization call, uncollected deductible, and overlooked filing deadline cost the practice money.
• Losses are not sustainable in today’s business of tight operating margins.
• Uncollected reimbursements due to leaks in RCM processes are preventable
• Every missed pre-authorization, uncollected deductible, eligibility verification, and overlooked filing deadline is lost revenue.

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Documentation, Coding, and Billing Specialist Certification (DCB-SC)
Documentation, Coding, and Billing Master Certification (DCB-MC)

Registration Now Open: Urology Advanced Coding and Reimbursement Seminar

Click Here to Register Now  

Las Vegas, December 1 & 2, 2023
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

New Orleans, January 26 & 27, 2024
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

Reserve your spot and save!

As a Urology Coding and Reimbursement Podcast listener, you get access to a discount (limited-time offer).

Use code: 24UACRS733

Get signed up today and get peace of mind knowing you will be prepared for all the upcoming changes.

Join the discussion:

Urology Coding and Reimbursement Group - Join for free and ask your questions, and share your wisdom.

Click Here to Start Your Free Trial of AUACodingToday.com 

June 16, 2023 

Mark, Ray, and Scott discuss questions that came up during a May monthly training webinar: Coding for prostatic artery embolization (PAE); Urocuff payment coverage, reports of diagnosis denials

 Urology Documentation, Coding, and Billing Certification

For Urologists and APPs
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Documentation, Coding, and Billing Fellowship - Urology (DCB-FS)

 For Coders, Billers, and Admins
(Click Here for Pricing, More Information, and Registration)

Documentation, Coding, and Billing Specialist Certification (DCB-SC)
Documentation, Coding, and Billing Master Certification (DCB-MC)

Registration Now Open: Urology Advanced Coding and Reimbursement Seminar

Click Here to Register Now  

Las Vegas, December 1 & 2, 2023
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

New Orleans, January 26 & 27, 2024
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

Reserve your spot and save!

As a Urology Coding and Reimbursement Podcast listener, you get access to a discount (limited-time offer).

Use code: 24UACRS733

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Join the discussion:

Urology Coding and Reimbursement Group - Join for free and ask your questions, and share your wisdom.

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June 9, 2023 

Mark, Ray, and Scott welcome back Dr. John Lin to discuss 2 questions that came into the Thriving Urology Practice Facebook Group [click to join].

1.  What codes should we be using for MRI fusion biopsy of the prostate? Is it all the TRUS biopsy codes (76872, 76942, 55700, 64450 A4512) with no additional?
2. Medicare denied a claim stating patient died 03/02/23. Actual date of death was 03/23/23, so this was obviously a data entry error. Any ideas how to correct? My biller says Medicare only accepts edits from patients, but that is unlikely to happen in this case (and if it does getting paid for the claim is the least of my worries).

 Urology Documentation, Coding, and Billing Certification

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Documentation, Coding, and Billing Fellowship - Urology (DCB-FS)

 For Coders, Billers, and Admins
(Click Here for Pricing, More Information, and Registration)

Documentation, Coding, and Billing Specialist Certification (DCB-SC)
Documentation, Coding, and Billing Master Certification (DCB-MC)

Registration Now Open: Urology Advanced Coding and Reimbursement Seminar

Click Here to Register Now  

Las Vegas, December 1&2, 2023
8 am - 4:30 pm Friday, 8 am - 3:30 pm Saturday

Reserve your spot and save!

As a Urology Coding and Reimbursement Podcast listener, you get access to a discount (limited-time offer).

Use code: 24UACRS733

Get signed up today and get peace of mind knowing you will be prepared for all the upcoming changes.

Join the discussion:

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June 2, 2023 

Mark, Ray, and Scott discuss coding for 2 E/M services on the same date/patient; coding for services provided to a patient from an SNF in the office.

This question originated from a comment on the Thriving Urology Practice Facebook Group [click to join]:

Jonathan Starkman

Thanks for posting John C Lin I would love to see how a commercial payor like UHC or Cigna would process 2 E/M claims on same day using a 25 modifier as in the first scenario presented...I'd bet a ton of money it would get denied, denied, denied I just wanted to comment on the last scenario which involved a cardiologist seeing a patient from a SNF in their office. The experts suggested using a code 99214. We have had a number of denials in this situation and it seems that because a patient is in a SNF or acute rehab facility they are still considered a "registered inpatient" and according to CMS would need to use inpatient CPT codes to bill for the encounter in your office. My administrator pulled this off our MAC website Outpatient Services for Registered Inpatients
There are occasional circumstances in which a registered inpatient may require a service that is not available at the inpatient facility. These inpatient facilities include acute-care hospitals (POS 21), skilled nursing facilities (POS 31), psychiatric inpatient facilities (POS 51) and comprehensive inpatient rehabilitation facilities (POS 61) as well as other types of hospitals represented by place of service (POS) code 21 unless there is a more specific POS code. Such outpatient services are performed on a same-day basis; the patient is transported to another facility or physician’s office and returned to the original facility on the same date of service.
When such services occur, the following rules apply:
For Part A services (nonphysician outpatient services) performed outside of the facility at which the patient is a registered inpatient:
The facility which provides a Part A service must seek compensation from the original facility at which the patient is a registered inpatient. That original facility is responsible for the cost of the service(s) performed at the outside facility and will make payment from Medicare’s reimbursement for the inpatient stay.
The original facility includes the nonphysician outpatient services on its inpatient claim. This is commonly referred to as under arrangement billing.
Examples of services that may be performed under these circumstances (generally referred to as “under arrangement”) include outpatient dialysis, radiation therapy, and diagnostic procedures such as MRI.
For Part B services at a physician’s office, performed outside of the facility at which the patient is a registered inpatient:
The physician’s office service must be billed with the POS code that reflects the inpatient facility at which the patient is a registered inpatient (i.e., POS codes 21, 31, 51 or 61 as described above).
The physician’s office service must be coded using a CPT code correlative to the POS code used on the claim. For example, an office service for a new patient would be represented by an inpatient CPT code in the range of 99221‒99223, while an office service for an established patient would be represented by an inpatient CPT code in the range of 99231‒99233.
The important factor here is that the POS code must correlate to the CPT code. Claim editing is set to allow a subset of CPT codes per POS and claims will deny when this correlation is not established on the claims. Such denials, of course, are subject to appeal. Would love to get your take on this or Mark Painter

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