Q.
My question concerns a difficult Foley insertion. If the physician wants to charge for the complicated insertion (51703), shouldn’t the reason why it was complicated be documented? I would think that just because the nurse could not perform the insertion and a physician had to be called in would not be enough to warrant the complication. If the reason was documented (eg, small urethra requiring dilation, stricture from previous prostate surgery, etc.), then the complicated CPT could be used. How much needs to be documented?
A.
You’re on the right track. You cannot charge for a complicated insertion just because the nurse could not perform the insertion.
However, the physician is being paid for a procedure, not a diagnosis. The proper documentation to support the “complicated” catheter insertion should include the type of difficulty the doctor had. The use of the special catheter, peritoneal manipulations, use of the catheter guide, etc., are a few suggestions. Documentation that the nurse could not insert catheter and the physician “inserted catheter without difficulty” does not warrant the use of the complicated catheter insertion code.
Q.
We are getting patients coming in for recurring “reproductive” visits, and the charges are described as “storage bill and cryo storage.” We are not sure if there’s a special code to use for these visits or simply the procreative management V.26.21 code.
A.
The procreative management codes are probably your best bet. However, the V.26.21 specifically states that it is for infertility testing. Use that one for the testing involved only.
However, for the storage you’re probably better off using the 26.9, procreative management, unspecified. I chose that one over the 26.8, procreative management, other specified, because I could not find a specific code for the procedures that you are charging for.
Q.
In the February Urology Times, you wrote that G0353 could not be charged with an office visit on the same day. If a physician sees a new patient and decides on an injection of antibiotics, does this mean there can be no office visit charge? Also, can a certified registered nurse practitioner participate and bill G codes for administering chemotherapy intravenously?
A.
For your first question, please see the correction above. Yes, you can charge an office visit on the same day as an injection if the visit qualifies for -25 modifiers, which should be added to the E&M code.
Yes, the CRNP can administer and charge for their services. These services can be charged by the physician under the “incident to” rules if the physician is immediately available. The charges can be made for the G codes requesting information about nausea, pain, etc. if the physician or other qualified Medicare provider is giving an intravenous fusion of chemotherapy.
Q.
If a leuprolide injection is given on a different day than a chemo injection, can they both be charged
A.
Yes. All injections are classified as “0” global and therefore do not affect payment for any services delivered the following day. Actually, you could charge for both if given on the same day. Injection codes are not bundled.
Q.
Should we be billing for a material tray with our prostate biopsies?
A.
For Medicare, the answer is simple and clear: No. The non-facility fee, which is the payment you will receive for an office procedure, has an increased payment over the “facility” fee you are paid if this procedure were to be performed in the hospital or an ambulatory surgical center. That extra amount of money is calculated to pay you for the needles, other supplies, office space, and office personnel. It would be inappropriate to charge separately for any of those items.
For private payers, it depends on many factors, all revolving around your contract with the payer, how they’re paying you, etc. If you’re being paid by the private payer a percentage of the resource-based relative value scale (RBRVS) and they are reimbursing you the non-facility fee, then the answer would again be no.
However, if they’re paying you the facility fee, then you should charge separately for supplies, a tray, facility fee—whatever they will pay.
Or if they’re paying you using their own fee schedule and the pay is proportionally less than what it takes to cover the cost of those supplies, then it would be appropriate to charge
Whether you get paid or not is a different story. These issues should be covered in your contract. If they are not in your current contract and you are being inadequately paid, be sure you cover it the next time you sign a contract.
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.
