Q:
Will the Office of Inspector General audit physicians for changing 4-month LHRH injections to 3-month injections and 6-month injections to 3-month injections? Also, will it flag you if you are changing from one 3-month injection to another 3-month injection?
A:
I do not think the OIG, the watchdog of the Medicare program, will penalize or fine anyone for switching from one drug or one formulation, such as a 3-month to a 6-month or vice-versa. After making such a bold statement, I should explain my reasoning. There are several overriding facts that we should keep in mind:
Physicians should determine what is best for their patients. The government has no way, nor should they, of determining what’s best for an individual patient. If it’s more convenient for the patient to be switched to a 6-month injection because of personal reasons, that should go unchallenged by the OIG. On the other hand, it may be more convenient for the patient to receive his shot on the same day you want to re-evaluate the patient. If that is at 3 months, then you should switch the patient to the 3-month injection.
The Center for Medicare & Medicaid Services has determined that all the LHRH drugs are “medically equivalent.” I do not see how they could object to switching from one drug to the other. There is no rule, regulation, or law that I can find that would give the OIG the authority to punish or fine anyone for switching from one drug to another.
Medicare has set the rules on how you buy drugs and what you will be paid for those drugs. You have to play the game by the rules.
You also have to figure ways that you can continue to provide good patient care, and that includes providing the drugs your patients need. You cannot afford to lose money and continue to provide those services. Therefore, you have to consider the economics of one drug versus another. Actually, in my opinion, you can justify changing drugs based on the economics.
Having stated my case, I will remind you that last November, the OIG published a warning about switching for economic reasons. This may have been a hollow threat in an attempt to keep physicians from switching to longer formulations at the end of last year, prior to the advent of the average sales price methodology. Or it is possible that CMS has a rule or regulation that I can’t find.
I cannot say with certainty that the OIG will not take action if you switch drugs, but I do not think it will, or legally can, do so.
Q:
We have been billing Bacillus Calmette-Guerin with code J9031 along with bladder instillation code 51720. On one of our recent billings, Medicare denied the 51720 as included with J9031. Has there been a change in billing for BCG?
A:
J9031 represents a request for payment for the drug only. The installation is not bundled into the drug. Therefore, charge for the installation separately, and you should be paid by Medicare. Appeal the denial.
Private payers, at times, do not pay when they should, even if the denial is not covered by their contract.
Q:
Occasionally, an extracorporeal shock wave lithotripsy procedure is not performed because the previously visualized stones are not seen at the time of treatment. The patient has been anesthetized, a fluoroscopic search is conducted, but treatment is not accomplished. Is there any code to allow charges for time spent by the urologist?
A:
Yes. You should charge for the procedure that was started but was not completed, in this case, the ESWL, with a –52 modifier (50590–52), and decrease the fee to the amount you think is appropriate. Beware. By charging for the ESWL, even with the –52 modifier, you will create a 90-day global, and the fee should take that into consideration.
Q:
I am new to urology billing. What books (besides the CPT and ICD9) do you recommend?
A:
A few books are an absolute must, such as CPT-2005, ICD-9, The Healthcare Common Procedure Coding System (HCPCS), and “Coding Tips” from AUA. Also are important are the Correct Coding Initiative (CCI), the Medicare carriers manual, all your local carrier decisions (LCDs), and a number of databases to which you should have access.
You can also sign up for a subscription to AUACodingToday http://www.auacodingtoday.com/ , which is free for 2005, thanks to an educational grant from Watson Pharmaceuticals.
Q:
Please clarify the use of G0353 for antibiotics, testosterone, and other therapeutic drugs, as the HCPC describes it as intravenous, versus G0351, which is described as subcutaneous, intramuscular in the February 2005 Urology Times article.
A:
G0351 is correct. The discussion and reference to G0353 in the February article was a misprint. For more information, see a discussion in the April issue of Urology Times or http://www.urologytimes.com/InjectionFAQs/
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
