We have answered several questions about urodynamics in our “Coding Q&A” column over the past 6 months. However, the issue is so important that we thought an article explaining the appropriate billing for urodynamics would be helpful.
In reviewing the data for multiple urology practices, the PRS Urology Data Initiative has shown that correctly billing for urodynamics has provided an immediate increase in income without adding new patients. Some are not billing for all the procedures that are normally performed, whereas others do not recognize that 51797 is an add-on code, while others are not billing according to the “incident to” rules.
Here’s a look at all aspects of urodynamics billing and the correct way to report services provided.
If you own urodynamics equipment and perform urodynamics in your office, you should bill for any or all of the following tests performed:
• 51726: Complex cystometrogram (eg, calibrated electronic equipment)
• 51741: Complex uroflowmetry (eg, calibrated electronic equipment)
• 51772: Urethral pressure profile studies (urethral closure pressure profile), any technique
• 51784: Electromyography studies of anal or urethral sphincter, other than needle, any technique
• 51795: Voiding pressure studies; bladder voiding pressure, any technique
• 51797: Voiding pressure studies; intra-abdominal voiding pressure (AP) (rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure.)
How you report the codes depends on how the services are performed in the course of treatment in your office.
‘Incident to’ rules:
Every procedure in the office is billed as if a qualified provider (the urologist, a physician assistant, or nurse practitioner) provided the service. Therefore, the nurse (or technician) who performs a test is not reimbursed; the service is instead charged as an “incident to” service by the qualified provider who is immediately available and in the office at the time of the procedure.
Services on same day by same provider
If you provide both the testing and professional interpretation of the urodynamics test on the same date, the correct reporting is:
• 51726
• 51795–51
• 51772–51
• 51784–51
• 51741–51
• 51797 (add-on procedure does not require –51).
Note that for Medicare, modifier –51 is not required, but the order on the bill should be listed as above.
Services on two days or by two providers
Many offices have a technician providing urodynamic testing on one day, for which a number of patients are scheduled. After receiving the results, the physician provides professional interpretation at a later date, such as the next patient visit.
Proper reporting for the provision of urodynamics under these circumstances should take place on the two separate dates of service in the manner outlined in the accompanying table.
At this point you may ask, “Why bother?” First and foremost, this is the correct way to code under the Medicare fee schedule and according to the “incident to” rules. If these procedures are performed on separate days and/or by different providers, they should be reported as such. In addition, billing on separate dates will increase your payment.
Factors affecting payment
The two rules that affect payment for these codes are as follows:
Add-on code.
CPT code 51797 is an add-on code, meaning it must be charged with the primary procedure (51795). The multiple procedure rules do not apply, and modifier –51 should not be used when reporting this code. The procedure should be paid in full without the 50%
multiple procedure reduction. If you review the code onhttp://AUACodingToday.com/, you will see that it has been listed as a ZZZ code on the global indicator.
Multiple procedure rules.
It is important to note that the codes for urodynamics are not purely surgical codes, even though they are contained in the surgery section. Medicare has applied the radiology multiple procedure reduction rules, which do not require the multiple procedure reduction of the technical component (TC) of these urodynamics services (with the codes billed with a TC modifier). However, the codes without the –TC are treated as surgery codes, and the multiple procedure reduction rules are applied if the service is billed without a –TC or –26 modifier, with the exception of 51797. Multiple reduction rules are applied to the professional component (–26) modifier codes.
The private payer has the ability to treat these services and the “incident to” rules, which require separate reporting for Medicare, differently than Medicare does. Therefore, unless you can negotiate a change, you truly are stuck with a decision to walk away, accept the lesser payment, or modify the services you offer to patients.
In the end, the decision of what to do and how to negotiate with each payer must be considered on a case-by-case basis. As such, the different way that each payer treats multiple procedure reductions and “incident to” services will affect your payment.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook.
Mark Painter is CEO of PRSUrology SC in Denver.
