Q
I read the article about “group shared appointments” in the Aug. 1, 2005, issue of Urology Times. Are there specific billing, coding, and documentation issues associated with this type of appointment?
A
Yes. Each and every service provided by a physician must stand alone. In other words, the service must be provided to the individual patient according to the payer rules, and the documentation for that service must accurately reflect the services provided that day. The payer should be billed for the services provided as documented in the charge.
The group shared appointment (GSA) is no exception. I think the authors of the article covered the key issues fairly well. As they indicated, you definitely could not charge for such an appointment based on time. Each patient should be evaluated and treated individually. Documentation must accurately record each en-counter, and billing should accurately reflect that individual encounter.
The fact that other patients are present and listening is not a billing problem as far as I know. I would be concerned about charging the last patient, who had no questions, for the treatment advice that I gave the first patient, even if the last patient were listening. However, if the complete history is filled out by each patient, the history is used by the physician in evaluating that patient, and all medical decision making for that patient is accurately recorded, that should not be an issue.
I am not aware of specific coding rules that prevent billing for services for patients participating in a GSA as outlined in the article. However, the payment system was designed for individual patient encounters, and this would appear to circumvent that intent.
If GSAs become prevalent, I would not be surprised to see a specific code or modifier that must be applied. Group therapy has been recognized and given specific codes in certain circumstances, and payment for these services has been adjusted accordingly.
Q
I perform transrectal ultrasound-guided prostatic biopsy in the hospital as an outpatient procedure (in a minor treatment room), utilizing the ultrasound machine and tech of the hospital to set up the machine and to size the prostate. I perform the TRUS and biopsy. In my operative report, I do mention my findings on the TRUS. How do I code these procedures to maximize reimbursement?
A
If you performed a diagnostic ultrasound and properly documented your findings, then conducted an ultrasound-guided biopsy and documented both of those procedures, then you should charge for the diagnostic ultrasound, ultrasound guidance, and needle biopsy. However, since you are using the hospital equipment, space, and technician, then you would add a modifier –26 to the ultrasound procedures. You will charge for the professional component (–26), and the hospital will charge for the technical component, as follows:
76872–26: diagnostic ultrasound
76842–26: ultrasound guidance
55700: prostatic needle biopsy.
Good news! Aetna has agreed to reverse its previous policy and pay for both the ultrasound guidance and the diagnostic ultrasound. If you have been denied payment by Aetna for those services, between Nov. 16, 2004, and May 14, 2005, you should resubmit the claim for payment. If you have been denied payment after May 14, 2005, you should appeal.
Q
I need coding clarification on the following scenario: cystourethroscopy, left retrograde pyelogram, and placement of the left ureter. What are the appropriate codes for the CPT/HCPCS, radiology, surgery, and the device?
A
I would need more specific information to properly answer your question. I will assume two scenarios and will give the proper coding for each one.
In the first scenario, the patient was scheduled for a left diagnostic retrograde, possible left ureteroscopy with lithotripsy. The left retrograde revealed an upper ureteral calculus, and the decision was made to do a ureteroscopy with lithotripsy. This was performed without difficulty. A double-J indwelling stent was inserted. Assuming all procedures were properly documented, including a separate dictation for the reading of the left retrograde, the procedures should be billed as follows:
52005–59
52353
52332–59
74420–26.
Note that the 52005 is bundled into the 52353 and cannot be unbundled according to the CCI.
However, the coding rules state that a diagnostic test leading to a therapeutic procedure should be paid along with the therapeutic procedure. As a result, you will be denied payment for the 52005; however, you should be paid when you appeal if you have clearly stated in the documentation that the retrograde was diagnostic leading to the ureteroscopy with lithotripsy.
In addition, Medicare will pay for the reading of the retrograde only once. If there are films for the radiologist to read, he will also bill. The bill Medicare receives first is the one that will be paid.
The second scenario is the same as the first, except the patient was scheduled for ureteroscopy with lithotripsy. The retrograde was performed to outline the anatomy to facilitate insertion of the guidewire.
The billing in this scenario would be 52353 and 52332–59.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
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.
