Q
How do I charge for a patient sent from a nursing home for a consult who, upon evaluation, required a cystoscopy?
A
For a routine nursing home patient, charge the appropriate level of outpatient consult with a –25 modifier, charge for the cystoscopy (52000), indicate the place of service as “office,” and you will be paid as you would for any other office visit.
If the patient is in the first 100 days of discharge from the hospital and Medicare is paying the bill through Medicare Part A to a skilled nursing facility (SNF), E&M servi-ces are paid as outpatient services in your office without a problem. However, any “procedure” will be paid as if it were perform-ed in a facility, or a “facility fee.” Any service you provide with a technical component and a professional component will only be paid for the professional component. Most important, drugs normally paid by Medicare Part B will not be paid by Medicare Part B when given to SNF patients.
You should have a contract with the nursing home to pay for these services because the SNFs are paid on the diagnosis related group (DRG) concept similar to a hospital. Any unpaid drugs, the difference between procedures paid at the facility fee and non-facility fee, and unpaid technical fees should be paid by the nursing facility if you have the appropriate contract.
Q
I work in an office with six physicians. We’ve set up an operative suite and are considering doing a photoselective vaporization of the prostate (PVP) laser procedure for BPH as an outpatient procedure in the office. We arranged for the anesthesia and all the safety equipment that is required. How do we bill for the procedure, and what will we be paid?
A
I have good news to report. Last year physicians used 52647, which paid both a facility fee for a procedure performed in the hospital in addition to a non-facility fee for a procedure performed in the office or other outpatient setting. A change in the terminology on the laser codes in CPT prevented 52647 from being a correct code for reporting the PVP procedure as of Jan. 1, 2006. As of this date, therefore, 52648 is the only correct code to use.
The good news came in a recent press release from PVP device maker Laserscope, which stated:
“The correct way to code the laser as an outpatient or inpatient is to use the 52648 in place of service, and the national average payment will be approximately $3,100 for the outpatient procedure and approximately $600 for the procedure if in the hospital.”
In summary, CMS finally agreed to pay the non-facility fee for the 52648 code as of the beginning of 2006. The new payment rule will apply to all laser treatments of the prostate that are described by that code.
Q
There are a number of different LHRH products now available on the market (both injections and implants). In the case of a Medicare patient who has no preference between an injection and an implant, is there any financial advantage of using one drug over the other?
A
The answer to your question depends on your contract for the drug. There are several issues to consider in making your decision. First, consider the spread between the cost of the drug and the payment you will receive from Medicare. Obviously, if you’re using a 3-month drug, that profit will occur four times a year, whereas an implant provides a once-a-year profit.
The other variables to consider are drug administration income, office expenses, and time. E&M visits should not enter into the equation. The Centers for Medicare & Medicaid Services has made it clear that you should only charge for an E&M visit when it is medically necessary. Theoretically, the number of visits should not vary with the injection versus the implant. The patient should be seen when medically necessary.
Take the injection fee for the drug and subtract the cost for that encounter, and multiply by the number of injections per year. Compare that profit to the implant fee minus the procedure cost for the yearly implantation.
Another key issue is the physician’s time. The physician usually performs the implantation, whereas a nurse or other medical assistant administers the injection. If the injection is chosen, the physician could use that time to see other patients. Once you add all of these factors together, you will have your answer.
Q
When doing ultrasound of the prostate alone or with a biopsy in the office, can we bill 76872-26, 76872-TC, and 99215?
A
If the urologist owns the equipment and actually performs the procedure, he or she should charge 76872, diagnostic ultrasound of the prostate, without a modifier. The ultrasound can be charged with or without the prostate biopsy when performed.
If the urologist provided a significant E&M service in addition to the procedure, then a separate charge should be made for the level of E&M service provided. For instance, following a diagnostic ultrasound and the discussion of findings, the urologist discusses the disease process and its treatment. In that situation, an E&M service would be appropriate at the level of service provided.
That level can be reached by either components or time. (Refer to the pocket card and wall chart for details.)
There is no set regulation that would allow the charge of a 99215 with a diagnostic ultrasound. Each E&M service that you provide has to be medically necessary, significant, and separate from the procedure you performed, and the reporting must accurately reflect services provided.
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
