Q
We are not getting paid for CPT 52332, insertion of J stent when done with 52353, 50590. I have appealed and have sent a copy of the Urology Times article from October 1999 (“Bill stent insertion separately from ureteroscope,” page 18). I have billed with and without modifier 59, but they are still not paying the claim. Do you have any suggestions?
A
First, I need to know who the insurer is. If it is Medicare that is not paying and you have billed 52332 with the 59 modifier with the 52353, I would take the appeal to the highest level. And if you still were not getting paid, I would ask my state medical society or my state urological society, depending on who has the coding clout in your state, to intervene. You should be paid for the 52332 in conjunction with the 50590 without the 59 modifier, since they are not bundled.
If this is a private insurance company, you may have a different problem. They can refuse to pay for anything. However, check the contract, and if it is not specifically stated that the company will not pay, then I would take the insurer to task. Again, your state society might be able to negotiate payment if this is a statewide problem. If you sued for payment, you would probably win.
On the other hand, if they refuse to pay, I would certainly keep that in mind when it comes time to sign the next contract. Either include specific language requiring payment or consider not signing, if feasible.
Q
Regarding your article in the February 2003 issue of Urology Times (“New residual urine code will be for non-imaging US only,” page 40), our urologists would like clarification on the difference between imaging and non-imaging ultrasound.
A
First and foremost, Medicare has not yet addressed this issue. CPT states that the non-imaging ultrasound used to check residual urine is the Doppler technology. CPT, also, under Diagnostic Ultrasound, defines four different types of ultrasound: A-mode, M-mode, B-scan, and real-time scan.
The CPT definition for 76775 is, “Ultrasound, retroperitoneal (eg, renal, aorta, nodes) B-scan and/or real time with image documentation; limited.” The CPT definition for 76857 is “Ultrasound, pelvic (non obstetrical), B-scan and/or real time with image documentation; limited.”
The CPT definition of B-scan is “implying a two-dimensional ultrasonic scanning procedure with a two-dimensional display.” Real-time scan is defined as “implying a two-dimensional ultrasound scanning procedure with display of both two-dimensional structure and motion with time.”
In my mind, the practical definition is that, if you are using a machine that has a drawing of a bladder or computes the ultrasound volume for you, then you are using a non-imaging machine. If your ultrasound gives you an ultrasonic printout showing not only the bladder but also all of the pelvic surrounding organs, then it is an imaging ultrasound.
Again, let me warn that we must keep abreast of any Medicare directives or local medical review policies that would direct you to use the non-imaging for residual urine, even if you are using an imaging machine. Medicare has the authority to make that decision.
Q
We have a policy in our office that was recently implemented and want to know if you have any information regarding it. We require co-pays and deductibles paid up-front before we do a vasectomy in our office. If any remaining balance is outstanding prior to the semen analysis, which we do as courtesy, it must be paid in full. What do you think?
A
I would agree with the requirements to collect co-pays and deductibles up-front and would work hard to be sure that we capture all the charges the patient should pay.
I have seen nothing in writing. However, I personally would be concerned about requiring the rest of the payment prior to a semen analysis for two reasons: good patient care and malpractice. Since post-op semen analysis is bundled into the procedure, it would be like refusing to see a patient post-op until they paid their bill.
Q
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A
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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.
