Co-pay, co-insurance laws differ by state.
But Medicare patients must pay 20% unless
they are financially incapable
Dec 1, 2002
By: Ray Painter, MD
Urology Times
Q. We see a lot of patients who are physicians and do not require them to pay co-pays. There are no enticements involved, but they do not have any financial difficulties. At a seminar, I heard that you should collect the co-pays but that you could choose not to collect the co-insurance. Therefore, should we start charging the physicians their co-pays?
A. Your question about co-pays and co-insurance is a good one that is misunderstood by many offices. The laws regarding co-pays and co-insurance may be different in each state.
In Colorado, it is a misdemeanor for a physician to not collect the co-insurance from any patient. In other words, if you charged a patient $100 for a service and the patient has a 20% co-pay insurance, $20 should be collected from the patient.
If you agreed to accept what insurance pays only and do not collect the $20 from the patient, then in reality, you’ve only charged $80 for the service and it is against the law to bill the insurance company for $100.
However, Medicare has made it clear that, in all states, the patient should be paying their 20% unless the patient is experiencing financial difficulty.
It is my understanding that, if you are giving physicians a discount, it could, under certain circumstances, be interpreted as a violation of anti-kickback laws, whether you intended it that way or not.
I do not give legal interpretations or advice. I recommend that you seek legal advice on this issue.
Q. Can you please provide the appropriate CPT codes for the following procedures: microsurgical epididymal aspiration of sperm, 16175; and intraoperative microsurgical sperm aspiration, 16666. The codes currently used are unlisted, and we encounter numerous problems when we try to justify the procedure to insurance companies. Providing the operative reports doesn’t always solve the problem.
A. I could not find the CPT codes 16175 or 16666. However, you are correct that neither microsurgical epididymal aspiration nor the intraoperative microsurgical sperm aspiration has a CPT code. The only way to bill for either of those procedures is to use the unlisted code. The appropriate unlisted code is 55899, unlisted procedure, male genital system.
When billing for an unlisted code, send the operative report, an explanation of the reason that the procedure was performed, and a “justification” to pay the fee that you have charged, along with the bill. That justification could be in the form of a comparable procedure, payable by that payer, that involves about the same amount of work and intensity and pays about the same amount you think is appropriate for the unlisted procedure.
Q. I’ve just started my own practice and am finding the coding to be a little confusing. Do you have any recommendations for resources or classes for someone in my position?
A. AUA puts on a series of seminars each year. Unfortunately the last one for this year has finished. Also, AUA’s “Coding Tips,” which is published yearly, has some valuable information on coding, specifically for urology coding.
In addition, Physician Reimbursement Systems (800-972-9298) has developed a CD-ROM that teaches the entire coding system, including documentation tips, correct coding for E&M service, use of modifiers, incident-to billing, etc. PRS also provides a Urology Billing Certification if one completes the course and passes a final test. This is an option to ensure that your coding staff is knowledgeable and up to speed on the latest information.
Other groups, such as the American Academy of Procedural Coders (800-626-CODE) and American Health Information Management Association (312-233-1100) have teaching aids for CPT and ICD-9 coding.
Q. We see a lot of patients who are physicians and do not require them to pay co-pays. There are no enticements involved, but they do not have any financial difficulties. At a seminar, I heard that you should collect the co-pays but that you could choose not to collect the co-insurance. Therefore, should we start charging the physicians their co-pays?
A. Your question about co-pays and co-insurance is a good one that is misunderstood by many offices. The laws regarding co-pays and co-insurance may be different in each state.
In Colorado, it is a misdemeanor for a physician to not collect the co-insurance from any patient. In other words, if you charged a patient $100 for a service and the patient has a 20% co-pay insurance, $20 should be collected from the patient.
If you agreed to accept what insurance pays only and do not collect the $20 from the patient, then in reality, you’ve only charged $80 for the service and it is against the law to bill the insurance company for $100.
However, Medicare has made it clear that, in all states, the patient should be paying their 20% unless the patient is experiencing financial difficulty.
It is my understanding that, if you are giving physicians a discount, it could, under certain circumstances, be interpreted as a violation of anti-kickback laws, whether you intended it that way or not.
I do not give legal interpretations or advice. I recommend that you seek legal advice on this issue.
Q. Can you please provide the appropriate CPT codes for the following procedures: microsurgical epididymal aspiration of sperm, 16175; and intraoperative microsurgical sperm aspiration, 16666. The codes currently used are unlisted, and we encounter numerous problems when we try to justify the procedure to insurance companies. Providing the operative reports doesn’t always solve the problem.
A. I could not find the CPT codes 16175 or 16666. However, you are correct that neither microsurgical epididymal aspiration nor the intraoperative microsurgical sperm aspiration has a CPT code. The only way to bill for either of those procedures is to use the unlisted code. The appropriate unlisted code is 55899, unlisted procedure, male genital system.
When billing for an unlisted code, send the operative report, an explanation of the reason that the procedure was performed, and a “justification” to pay the fee that you have charged, along with the bill. That justification could be in the form of a comparable procedure, payable by that payer, that involves about the same amount of work and intensity and pays about the same amount you think is appropriate for the unlisted procedure.
Q. I’ve just started my own practice and am finding the coding to be a little confusing. Do you have any recommendations for resources or classes for someone in my position?
A. AUA puts on a series of seminars each year. Unfortunately the last one for this year has finished. Also, AUA’s “Coding Tips,” which is published yearly, has some valuable information on coding, specifically for urology coding.
In addition, Physician Reimbursement Systems (800-972-9298) has developed a CD-ROM that teaches the entire coding system, including documentation tips, correct coding for E&M service, use of modifiers, incident-to billing, etc. PRS also provides a Urology Billing Certification if one completes the course and passes a final test. This is an option to ensure that your coding staff is knowledgeable and up to speed on the latest information.
Other groups, such as the American Academy of Procedural Coders (800-626-CODE) and American Health Information Management Association (312-233-1100) have teaching aids for CPT and ICD-9 coding.
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.
