Q.
I’m currently working for a large urology group, and the code 51792 has come up for urodynamics. Can this be billed, and can you reference a definition of that code? There seems to be a misunderstanding of how the code is used.
A.
In determining when and how to use a code, the primary issues to address are the performance definition, bundling, and last but certainly not least, medical necessity.
Code 51792 is “Stimulus-evoked response (eg, measurement of bulbocavernosus reflex latency time).” Typically, this requires an instrument that allows you to measure in milliseconds the time it takes from stimulation of the tip of the penis to recorded conduction of the nerve impulse to the bulbocavernosus muscle.
Commonly, this is measured by placing two stimulating rings at each end of the penis, with needles inserted in the bulbocavernosus muscle. The test can measure the effect of denervation in the area. There are other methods used to perform this test; however, the base definition will require the measurement of the response time once a stimulus is delivered.
Code 51792 does not preclude billing for any of the other urodynamics codes on the same visit, according to the National Correct Coding Initiative.
Ultimately, medical necessity must be met in the eyes of the physician before the service is billed and in the eyes of the payer before it is paid. Unfortunately, physician and payer determinations of medical necessity do not always match.
The following are two separate statements for local coverage determination (LCD) policies by Medicare Administrative Contractors relative to code 51792:
• TrailBlazer Health Enterprises, LLC: “Stimulus-evoked response has a limited application in practical urology but can be used to evaluate cases of suspected cauda equina syndrome.”
• Palmetto GBA, LLC: “Stimulus-evoked response: This study measures bulbocavernosus reflex latency time, and may be needed to make a more definitive diagnosis of pelvic floor (sacral reflex arc) denervation. This test is also used for suspected cauda equina syndrome.”
Therefore, documentation of the need to study denervation of the pelvic floor would seem to be required to support payment of the code. Additionally, you may run into some payers that will not pay for the service until there is a review of documentation relative to medical necessity, and others that will not pay for this service unless there is an issue related to cauda equina syndrome.
Another aspect of medical necessity that you should consider with respect to all tests but in particular to 51792: “The use of any of these procedures in a screening capacity does not represent a payable service.”
The above statement is also pulled from an LCD related to urodynamics coding. However, the statement is not limited to any one LCD but is commonly included in them. Translated, the statement requires that services billed to Medicare, unless otherwise indicated, should be billed because the physician has identified symptoms that need to be further analyzed to make a diagnosis and decide treatment and that the test ordered is based on the presenting symptoms.
Q.
We have several patients who are on finasteride (Proscar) therapy and undergo repeat PSA screenings every 6 months using code V58.69. Is this correct, or is this only covered once per year?
A.
The screening code for PSA (G0103) with diagnosis (V76.44) is only paid once every 12 months by Medicare. It should be reported for patients with no symptoms of prostate cancer.
Code 84153 is used to report the provision of a PSA test that is not considered to be screening in nature. The diagnosis code you listed, V58.69 (“Long-term current use of other medications”), is not listed on LCDs as either covered or non-covered. As such, coverage will vary.
Several other ICD-9 codes related to prostate cancer will most likely be paid by Medicare when submitted (see table).
However, you should be careful to consider all issues, including the limitations listed below from the PSA national coverage determination from Medicare:
• “Generally, for patients with lower urinary tract signs or symptoms, the test is performed only once per year unless there is a change in the patient’s medical condition.
• “Testing with a diagnosis of in situ carcinoma is not reasonably done more frequently than once, unless the result is abnormal, in which case the test may be repeated once.”
This narrative descriptive of limitations would indicate that Medicare can review patient medical records for evidence of change in the patient’s medical condition as a key indicator as to whether a PSA test should be considered reasonable and necessary for payment.
Q.
In a previously published article, you encouraged offices to bill private payers differently than Medicare. Isn’t it illegal to have different fee schedules and charges for different payers?
A.
This question represents a common misconception. The only requirement for a fee schedule and subsequent collections is that you do not charge more to a Medicare patient than you would to another patient in your office. Obvious exceptions to this rule are write-offs for patients who have financial hardships.
In fact, if you have a contract with a payer, you have most likely already determined that you will accept payments at levels different from your Medicare reimbursements; in effect, you are establishing a fee schedule that is different from Medicare. Thus, if it were illegal to charge patients with different payers differently, then all contracts would be illegal. At this point, they are not.
This brings up another issue that many practices have begun to implement in response to the increasing number of patients who have lost their insurance coverage during the recession: cash discounts or decreased fees for self-pay patients. These discounts are a sound strategy for most offices, as they can be offered prior to service provision and will increase the likelihood of payment and decrease the number of write-offs. As the amount of work and cost of collection at the time of or prior to a service is decreased, it makes sense to offer patients a significant incentive to pay for the services they will be provided.
Discounts are a great incentive. Make certain all non-financial hardship discounts, be they published or pre-set, stay above Medicare rates.
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.
