Q.
I work for four urologists who do not currently agree on who should bill for services done by the nurse. They all bill under the same tax ID number since they are all belong to the same group. Should the physician who is in the office bill for it, or should the physician who the patient sees on a regular basis, even if he is not in the office? I did see a similar question answered previously, but my docs want to know if the answer is different when it comes to groups.
A.
Unfortunately, the answer is the same. All services provided in a physician’s office are charged as if the physician provided the service. The charges made by a physician for someone else’s services provided in the office are called “incident to” charges. The “incident to” rules clearly state that a qualified provider must be immediately available—more specifically, in the office—at the time the services are provided. The physician in the office and overseeing the service is the one who should charge for that service, even if all the physicians are in a group practice and even though the patient is another physician’s patient.
Q.
Is injectable verapamil hydrochloride (Calan, Isoptin) billable when used routinely with procedure code 54200? We cannot locate a valid code, and since we incur the cost of purchasing the medication ourselves and do not receive any reimbursement, we thought it might now be billable.
A.
Most drugs injected in the physician’s office should be charged using the appropriate J code. An exception is that Medicare will not pay for drugs that are self-administered more than 50% of the time. I cannot find a specific J code for verapamil. Therefore, you would have to use the appropriate unlisted J code, J3490.
Q.
Will docetaxel (Taxotere) be reimbursed in a manner similar to LHRH agonists such as leuprolide acetate (Lupron)?
A.
All drugs that are provided to patients by a physician in the office that are paid for by Medicare will be paid at 106% of the average sales price. That includes both leuprolide and docetaxel.
Q.
I am a coder at a medical facility where the urologists are performing a nephrostogram through a nephrostomy tube. Following the nephrostogram, the patient’s nephroureteral stent is exchanged. Is there a CPT code for this part of the procedure?
A.
The question cannot be answered with the information given. One would have to know how a stent was removed and reinserted. If the stent was inserted from below through a cystourethroscopy, then you would use code 52332. If the stent was removed and reinstalled by renal endoscopy, then code 50553 would be most appropriate.
Q.
I do coding for three urologists. One of them has recently asked to bill 52351 bilaterally, using a -59 modifier. The bilateral rule does not apply to 52351, so I don’t think using a -59 would be right either.
A.
Normally, I would agree. If the rules state that you should not bill a procedure bilateral using the -50 modifier, then it would be inappropriate to bill using the -59 modifier.
However, in this case Medicare is incorrect in stating that you cannot charge for this procedure bilaterally. This is an unfair edit. Medicare had applied this edit several years ago to most of our endoscopy procedures, and AUA was successful in removing the edit for all, including bilateral ureterscopy, with the exception of the bilateral retrograde. You should be paid for both sides. In the past you were able to charge for bilateral ureterscopy using the -50 modifier.
Therefore, until AUA can get the edit removed, I would recommend billing with the -59 modifier since the procedure is on a different part of the body. For Medicare, bill 52351-50. For private payers, bill 52351 and 52351-50.
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.
