Every procedure in the office is billed as if a qualified provider (the urologist, a physician assistant, or nurse practitioner) provided the service.
Q:
My practice owns an ambulatory surgery center, and we’re interested in performing non-ASC-approved procedures, both for patient comfort and convenience. We have been told different things about reimbursement for these procedures. Our current thinking is that non-ASC-approved procedures performed at an ASC automatically get reimbursed at the in-office rate, and that there is no separate ASC component. Is that correct?
A:
Your thinking is absolutely correct. Performing a non-ASC-approved procedure in an ASC is billed by the physician for the physician’s service(s) at an outpatient procedure rate with ASC listed as the place of service. Medicare will pay the non-facility fee to the urologist, just as if the procedure had been performed in the office.
The ASC cannot bill a facility fee to Medicare. However, the physician could pay a portion of his fee to the ASC for the supplies and services provided by the ASC.
Requirements for private payers may be different. We have seen many arrangements, from separate service fees for the facility to all-inclusive package pricing. You will need to check with the payer prior to providing each service, unless you have been clever in contracting.
Q:
I read your article about coding and reimbursement of urodynamics (“Is it time to dump a payer? Many factors to consider,” January 2007, pg. 18). The current way we bill for urodynamics is by using the codes and modifiers 51726, 51795–51, 51741–51, 51784–51, and 51797–51. I understand the private payers will have different reimbursement rules, but as far as Medicare goes, how do I bill these codes for optimum reimbursement using –TC or –26 modifiers so the doctor can be reimbursed for reading the results and the nurse can be reimbursed for performing the tests?
A:
Every procedure in the office is billed as if a qualified provider (the urologist, a physician assistant, or nurse practitioner) provided the service. Therefore, the nurse who performs the test is not reimbursed for performing the test. However, the service can be charged as an “incident to” service by the qualified provider.
In other words, the qualified provider overseeing the work of that nurse is considered to have performed the test in the eyes of Medicare. Therefore, you should charge the codes without a modifier (as you have listed in your question with a modifier –51) for Medicare if the same provider oversees the test and reads the test the same day. However, if one doctor is in the office while the nurse performs the test and another doctor reads the test at a later time, then the procedure code is charged with the –TC modifier after each code on the date it is performed by the nurse under the number of the physician who is in the office on that day. The code is charged again under the provider number of the urologist who reads the test on the day that the test is read, this time with a –26 modifier for each code.
Similarly, if the test is performed one day and the same urologist reads the test on another day, charge the code on the date the test was performed with the –TC modifier and then on the date the test is read with the –26 modifier. Although this is the correct way to code, some carriers do not accept separate billing using the –26 and –TC for urodynamics billing. We do not recommend billing this way unless you have justifiable circumstances for doing so.
For a private payer, add the –51 modifier to the lesser procedures.
In answer to your question about billing for optimal reimbursement, you don’t. You have to bill according to the rules as to how the procedures were performed. Correct coding is always the best way to be appropriately reimbursed. Having said that, the pay will be slightly better if the procedures are charged separately on separate dates with the –TC and –26 modifiers. The multiple procedural reduction rules are not applied to the technical components; only the full codes and the professional component (–26 modifier) will be reduced under multiple procedure rules.
Q:
Where is the best place to find the Medicare bundling edits?
A:
The web site, http://AUA.codingtoday.com/, provides up-to-date bundling edits in a user-friendly format, along with a bundling tool that will answer your questions about bundling.
http://AUA.codingtoday.com/ is a coding reference resource database provided free to all urologists by AUA, thanks to a generous educational grant from Watson Urology. If you are not using it, go to the web site or visit the AUA or PRS booth at the upcoming AUA annual meeting in Anaheim, CA.
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.
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.
