Part B Insider (Multispecialty) Coding Alert

Determine whether in-office performance is profitable enough for your practice.

Now that you have codes to report the UroLift® procedures your urologist performs, you’ll need to analyze your practice’s reimbursements for these procedures.

“The establishment of CMS reimbursement for UroLift is a major milestone for NeoTract and the clinical Community, and comes on the heels of positive coverage decisions from Aetna and Coventry earlier this year,” said Dave Amerson, president and CEO of NeoTract, in the press release. But how is your practice going to be affected?

Take a look at the relative value unit (RVU) breakdown for 52441 and +52442 for both non-facility and facility places of service in the table below.

* Non-facility practice expense RVUs include the cost of the delivery device

Review the Numbers

Using an example of a UroLift® procedure with four implants, here is how your reimbursement will shake out in the first quarter of 2015, based on the current conversion factor that is in effect through March 31 of this year.

Office procedure: If your urologist performed the procedure in the office, you’ll report 52441 and +52442 x 3 for the four implants, and calculate the following:

34.90 RVUs + (3 x 26.69 RVUs) = 114.97 RVUs

114.97 RVUs x $35.7547 = $4,110.72 total reimbursement based on the 2015 unadjusted Medicare physician fee schedule

ASC procedure: If your urologist performed the procedure in an ASC, you’ll still report 52441 and +52442 x 3 for the four implants, and calculate the following:

6.54 RVUs + (3 x 1.75 RVUs) = 11.79 RVUs

11.79 RVUs x $35.7547 = $421.55 total reimbursement based on the 2015 unadjusted Medicare physician fee schedule

Analysis: The UroLift® delivery device will cost your practice $850 per device, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. Each UroLift® device supplies one implant.

“The average number of implants used is between four and five implants,” Ferragamo adds. For 2015, payment for 52441 and +52442 include the implants, and you should not bill separately for them. You also cannot bill separately for the delivery devices. Therefore, your practice will pay $850 x 4 for a procedure requiring four implants. If you receive $4,110.72 for the office procedure, but pay out $3,400.00 for the devices, your office profitability will be about $711.