Q
I am being denied payments for PSA tests. I have been billing 84153 with the diagnosis of V 76.44. What am I doing wrong? Many of my colleagues state that they are being paid for all of their PSAs.
A
There are two sets of codes for PSA tests. First are the CPT codes 84152-84154, and the other is a Health Care Procedure Coding System (HCPCS) code specifically for a screening PSA, G0103. There are specific diagnoses that are acceptable to both sets of codes. The screening PSA only can be charged once a year; if charged within less than 12 months of the previous charge, it will be denied by Medicare. The G0103 code is to be used only for the individual in whom you’re checking the PSA and who has absolutely no BPH, elevation of their PSA, or any other signs or symptoms of lower tract disease. This code is used strictly when PSA is given as a screening test, and for this, the correct diagnosis is V 76.44.
The appropriate CPT code(s) should be used for all PSA tests that are charged during the course of evaluating a patient with the diagnosis-appropriate disease process, such as BPH (600.01). There is a national payment policy that delineates the diagnosis codes that will allow payment for many CPT codes. For example, reporting 84153 with the diagnosis of chronic prostatitis (601.1) will be denied. 600.00 and 600.01 (BPH without and with symptoms of urinary obstruction) will be paid.
If you don’t know the codes, then please either view them on the CMS site http://www.cms.hhs.gov/ or the http://AUACodingToday.com/ site, which lists the codes as well. Do not mix and match. Do not use a screening code with a disease diagnosis, and do not use the screening diagnosis with CPT codes.
Q
I am a practicing OB/GYN in Virginia. My question pertains to the billing of an E&M service with newborn circumcisions. It would seem reasonable to me to bill for evaluation of newborn before circumcision, ie, inpatient consult if written request from pediatrician is on chart and note with adequate documentation is provided. Your thoughts would be appreciated.
A
As with any consultation, you must consider the basic requirements.
Was the visit requested by another physician or appropriate source? In this case, the pediatrician is another physician.
Are your findings and recommendations documented? As noted above, you have adequate documentation.
Did you communicate your findings and recommendations in writing to the requesting source? The hospital has a shared medical record, so separate documentation or a letter is not required.
It is not clear in your example whether this should be billed as a hospital visit due to a transfer of care or if it qualifies for an inpatient consult. A transfer of care can occur for the care of a specific problem. Why is the pediatrician requesting your advice or opinion regarding treatment of foreskin? Or is the pediatrician asking you to provide circumcision for the patient?
If, in fact, the pediatrician is asking you to provide the services, then the visit should be billed as a subsequent hospital visit and should not be charged as a consult. However, a legitimate request for your advice or opinion regarding treatment of the problem and continued involvement in patient care by the pediatrician will meet the qualifications of a consultation. As an OB/GYN, you will need to be very careful and document clearly, as the likelihood of review is greater.
Q
I am a private practice urologist who recently began performing a procedure for female stress urinary incontinence using the Renessa System (Novasys Medical, Newark, CA). This is a radiofrequency-based, in-office procedure to help stabilize the bladder neck and urethra. How do I code/bill for this global office procedure? Is it an unlisted code, or is there an assigned code? We are not being fully reimbursed.
A
As with other new technology, understanding coding is paramount to obtaining reimbursement. As you know, Renessa, like many BPH therapies, does require the purchase of equipment and supplies for provision in the office. Until recently, the only coding option was the use of an unlisted code.
A new category III code for Renessa was released by the American Medical Association in July. Relative Value Studies, Inc. released a value for the new code later in the same month.
The new code, although released by the AMA, will not be officially recognized in the CPT manual until Jan. 1, 2009. Payers may choose to implement the new category III code, but many will likely require the use of an unlisted code (53899 or 58999) until Jan. 1, 2009. After this date, the new category III code 0193T will be required for all claims submitted to payers unless specifically instructed not to use the code. Therefore, at this time, you will need to check with your payer to determine the best code to use for this technology: the unlisted code 58999 or the category III code 0193T.
It is important to note that category III codes and unlisted codes require coverage decisions to be made by each carrier. Until coverage decisions are made by the payer for new technology, each claim is typically denied and resubmission with paperwork is required for payment. However, once a coverage decision is made regarding new technology, a category III code can be processed like any category I code without manual intervention. Not all payers are capable of automatically processing unlisted codes.
The information in the table below may be helpful in developing reimbursement from payers that will provide sufficient revenue for provision of this service in your office.
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.
