As all urologists know, private payer rules differ from Medicare rules. From payment for procedures to globals, bundling, coverage, and modifier usage, private payers are not required to use Medicare rules.
Physicians, billers, and coders all have worked hard over the years to learn Medicare billing rules. Unfortunately, many of us have billed private payers using the same rules. In fact, that is precisely the teaching of some of our certified coders. Unfortunately, private payers do not always use Medicare rules. In fact, most payers, even those that say they use Medicare rules, do not always pay physicians based on Medicare rules. In this article, we will discuss some of the variations that you should look for in payments from private payers.
How Medicare, private payers differ –
The foundation for coding is Current Procedural Terminology. However, it’s important to remember that payer rules trump CPT rules. Even though many payers pattern their billing after Medicare or may use the Resource-Based Relative Value Scale, they do not always follow Medicare rules. Here are some ways in which Medicare and private payers differ:
Incident to’ billing. Medicare has very strict “incident to” rules. The doctor has to be in the suite and immediately available in order for a service to be billed. The service provided is reported as if the billing provider provided the service.
Private payers may have a more relaxed rule. Specifically, one Blue Cross plan requires that a physician be within 20 miles of the office and immediately available by phone. Others require only phone coverage, and still others have different distances for proximity when the service is provided. You may need to check with your payer for the specifics.
Bundling –
This is a big issue. Most urology offices rely on Medicare’s Correct Coding Initiative to determine the correct way to bill multiple procedures. Approximately 80% of all payers use McKesson Corp. software for their bundling edits and not the Medicare CCI edits.
The McKesson edits are very flexible, allowing payers to turn edits on and off as they choose. For example, they can choose to bundle urine analysis into your office visits, or they can choose not to pay for the –25 modifier. They can also choose not to pay for any procedure that is designated as a “separate procedure” if another service is provided on the same date. On the other hand, the payer may pay for two procedures performed together even though Medicare does not.
Unfortunately, McKesson does not allow for the publication of some of its edits, and most payers do not choose to make all of their edits public. As such, you are required to discover these edits by trial and error, at least until we are able to detect these edits and share them across practices. Also note that payers do not always behave consistently, even when patients have similar benefits.
Office supplies –
Do you have a payer that pays you the same for a cystoscopy in the office as it does for one performed at the hospital? If so, the payer is not paying you for your office supplies. Some payers will pay for supplies in the office if they are separately reported using Healthcare Common Procedure Coding System codes. You may be able to negotiate a “facility fee” for performing certain procedures in your office with other payers.
Modifiers –
Medicare will pay for evaluation and management services provided on the same day as a procedure with a –25 modifier attached even if the diagnosis is the same. Medicare will not pay for an E&M service reported with a –57 on the same day as a 0 or 10 global procedure. Medicare will pay for an E&M service provided the day before or the day of a 90 global procedure with a –57 modifier even with a diagnosis that is the same as the procedure. Medicare has no restrictions for the payment of an E&M service, billed with a –25 modifier on the same day as a 90 global procedure, but it may require a different diagnosis or require a documentation review prior to payment. Private payers may not have the same rules. Therefore, if a private payer does not pay you for an E&M service with the –25 modifier in which you evaluated a patient and made the decision to perform a 0- or 10-day global procedure, then use the –57 modifier and see whether the code is paid. Others may require a different diagnosis for payment.
Modifiers –59, –RT, –LT, and –50 also may be treated differently by private payers. Again, this may be something that you need to discover by trial and error, as contracts often do not spell this out.
Global rules –
Medicare has assigned global rules to every procedure. Each global rule designation is listed within the published guidelines and may affect both preoperative and postoperative reporting of services. Procedures assigned a 0-, 10-, or 90-day global have set pre- and postoperative time frames that require inclusion of certain services. However, unrelated services and certain related services may be reported and paid if appropriate modifiers are used.
Private payers may have different global periods and associated rules. Some payers will use the Medicare-developed postoperative period global periods but may assign longer preoperative periods for each case. For example, Medicare’s global for a transurethral resection of a bladder tumor is 0 days. A private payer may have a global of 30 to 60 days for a TUR of a bladder tumor.
How to proceed –
With all of these differences in mind, what should you do? How should you bill private payers? What rules should be used?
The answer is simple: Bill according to the payer rules for that patient. The problem is that we do not always know the payer rules, so the execution of this seemingly simple guideline is very difficult.
What this leaves you with in the short term is a conundrum: Do you bill only what you know will be paid and pursue a clean accounts receivable (A/R), or do you experiment with charging payers differently for the services provided and live with a slightly bigger A/R and more work to determine what can be paid for and what cannot?
We recommend the latter. Medicare payer rules are published; each office should do its best to follow the rules regardless of how unfair they appear to be. With private payers, we encourage you to consider CPT guidelines and what should be paid for fairly when deciding what to bill. Obviously, unbundling of services and going against what is ethically wrong is not an acceptable approach. However, billing for services provided and supplies that are used and not separately paid for is something every office should pursue.
The ultimate goal is consistent, accurate, and fair payment under each contract or situation. This should be undertaken with an ever-evolving set of protocols and responsibilities that encompass both you and your team. Happy hunting.
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Help prepare yourself for ICD-10 codes with this guide. Read more at: http://www.urologytimes.com/ICD-10
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 PRS Urology SC in Denver.
