Q
Why can’t pharmaceutical companies support educational programs about coding and Medicare billing rules? Is it related to the TAP Pharmaceuticals settlement?
A
I reviewed the Office of Inspector General (OIG) Compliance Program for Pharmaceuticals published in the Federal Register (April 18, 2003; pages 23731-43) and found no restriction to a pharmaceutical company sponsoring an educational program or providing materials related specifically to coding, Medicare payment rules, and other related topics.
To verify my interpretation, I called the contact number listed on the first page of the guidelines. After reviewing the guidelines and my comments, I was told that my interpretation was correct.
I had heard that the reason pharmaceutical companies had backed away from reimbursement-related issues was secondary to the TAP Pharmaceutical Products settlement.
After studying the integrity agreement, I found a provision for “a yearly review of expenditures for third-party advice about reimbursement or claims submissions for government-reimbursed products” as a part of TAP’s sales and marketing activities. No other references were found.
This review relates specifically to any reimbursement activities involving the selling or marketing of TAP’s products to the government. Coding and reimbursement in regard to correct documentation and accurate reporting of services was not a part of that exclusion.
I was told by the OIG’s office that the TAP integrity agreement was written specifically for TAP and the specific issues related to the company. Other pharmaceutical companies should not draw any conclusions based on this agreement.
In summary, the sudden lack of support for these very important products and services is probably a result of misinterpretation of the guidelines by the corporate legal staff and an overreaction in an effort to avoid any OIG questions. I can find no concrete reasons that companies should not support value-added services of this type.
However, they cannot tie participation to prescription writing or ignore the “insignificant gift rule.”
Q
We are having a problem getting reimbursed for CPT 50590 when performed with 52353-59 and 52332-59. The insurer is Regence. Our primary procedure is 50590. Can you tell me what we are doing wrong?
A
First and foremost, you should be paid for all three procedures. For Medicare, we have a special and-I would like to say “unusual” but, unfortunately, I will have to say “unfair”-edict developed for this situation.
Code 50590 is bundled into 52353, and 52332 is bundled into 52353. Herein lies the problem. The primary procedure is bundled into the lesser procedure code; therefore, the appropriate coding per NCCI is 50590-59, 52353-51, and 52332-59-51. As you know, private payers are not required to follow NCCI or Medicare guidelines by rule; therefore, the payment for these codes may require appeal.
Future avoidance of non-NCCI edicts can be done by adding verbiage to the contract requiring the adherence to NCCI guidelines and edicts.
Q
Would the use of the 51 and/or 59 modifier appended to code 55700 prompt payment for 76872 and 76942 if performed on the same day by the same physician?
A
Unfortunately, no. The ultrasound codes are not bundled, nor are they considered procedures. All three should be paid. However, some payers refuse to pay for all three.
Q
For billing, is it appropriate to add the 59 modifier to a bilateral procedure that requires two different incisions (ie, bilateral inguinal hernias [49500], bilateral orchidopexies [54640], or a hypospadias [54324] and orchidopexy)?
A
No. The bilateral modifier is 50. Actually, the payment is no different. Modifier 59 will allow payment but will still be 50% for the second procedure-exactly the same as 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.
