Urology Coding Alert

CMS reaches out to confused urology Coders with the answer to its million-dollar question: How should coders treat claims for Lupron injections administered to SNF patients? Where to find this treasure: CMS' SNF learning network Web site.
 
The battle for skilled nursing facility (SNF) patient reimbursement has begun, and the only way to come out on top is to get a firm grip on which services fall under the SNF consolidated billing guidelines - and delineate the services that require you to code technical and professional components separately.
 
"CMS has a Web site dedicated to SNF education," says Jeane Capers, RHIT, coding compliance officer with West Texas Medical Associates in San Angelo. "The CMS site is www.cms.hhs.gov/medlearn/snfcode.asp." The site contains four files of CPT codes that can or cannot be billed directly to Medicare Part B, she says.

Put the Files to Good Use: Locate Lupron

The area that is giving coders the most difficulty is coding claims for Lupron administered to SNF patients. When your urologist provides services to a Medicare beneficiary in a Part A covered SNF stay, look up the codes in the four files for what the urologist provided to see where the services are listed - where you find the code will determine how you code the service.
 
You must report the supply of Lupron (J9217, Leuprolide acetate [for depot suspension], 7.5 mg), a drug that urologists frequently administer to their patients, to the SNF because it falls under the consolidated billing rules, Capers says. The same holds true for Zoladex (J9202, Goserelin acetate implant, per 3.6 mg), which must be billed to the SNF, not the carrier.
 
The coding translation: Do not attempt to get reimbursed by Medicare Part B for either the supply of the drug or the injection of the drug (96400, Chemotherapy administration, subcutaneous or intramuscular, with or without local anesthesia). Both the supply and the injection itself should be submitted to the SNF. You cannot separate the technical and professional components of these services.
 
"[Lupron and Zoladex] are typically administered infrequently and in a general practitioner's office," says Thomas Hoyer, director of CMS' Center for Medicare Management Chronic Care Policy Group. "They are not identified as being beyond the general scope of care that a SNF would normally furnish. Additionally, in identifying certain specific chemotherapy codes for exclusion from SNF consolidated billing, Congress has considered these two codes in the past but has not decided to add them to the exclusion list. Therefore, it is our determination that these codes continue to be subject to consolidated billing."
 
Also remember that you have to check with the nursing facility the same day that you render Lupron shots or any other services to the patient, says Barb Livingstine, office manager for Executive Urology. "We realize that their status can change on a daily basis, so we would have to check with the nursing home before giving the shot to be sure they are intermediate care for that day." Her foolproof method: "We call the SNF the day of the patient's visit" to be sure the coding and billing staff knows the patient's current status.
 
And don't stop at investigating the patient's status. "Find out to which benefit the patient's charges are being billed by the nursing home on that day," says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC. "If it's Part A, then it's consolidated."

Navigate the Site With Ease

Don't limit your use of CMS' Web site to looking up Lupron and Zoladex coding guidelines. The site is filled with valuable information, but if you don't know where to find what you're looking for, you could spend hours trying to locate it.
 
The information that concerns your coding most is in the section containing SNF provider and supplier coding files for claims submitted on or after Jan. 1, 2003, which determines how you code services your urologist is now rendering to patients in SNF Part A covered stays and Part B noncovered stays.
 
"Files 1 and 2 are the ones I am most interested in," Capers says, because File 1 lists all of the codes the physician can bill directly to Part B, and the codes listed in File 2 are those professional services not subject to consolidated billing. These services should be submitted to Medicare Part B with modifier -26 (Professional component).
 
The first three files - Physician Services, Professional Components of Services to be Submitted with a 26 Modifier, and Ambulance - apply only to those beneficiaries in a Part A covered SNF stay, according to CMS.
 
Files 1 and 2 contain lists of services that can be separately billed to the Medicare carrier by the physician, nonphysician practitioner, or supplier. Translation: To get reimbursed for the codes listed in File 1, you must submit a claim for the entire service to the Part B carrier. But to get reimbursed fully for the codes listed in File 2, you must code the technical component and submit the claim to the SNF that sends the claim to the fiscal intermediary (Part A). The claim is then reimbursed to the FI, and it is the SNF's responsibility to pay the provider for the services rendered to the patient. The coder should then code the urologist's professional services with modifier -26 and submit that claim directly to Medicare Part B.
 
"The urodynamics codes 51725-51797 fall into this group, and when they are billed to Part B Medicare you should append modifier -25. Also included in this group are genitourinary radiological codes 74400-74485, 76775, 76857, 76870, 76872 and 76942," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.
 
As for codes not listed in Files 1 and 2, these services fall under the consolidated billing requirements, Capers says, and the physician, nonphysician practitioner, or supplier must seek reimbursement directly from the SNF. Don't separately code the professional and technical components of these procedures. Submit a single claim directly to the SNF for all of the services rendered.
 
Capers says that if you look at the codes listed in File 1, you will find many codes other than E/M services that a physician can bill directly (and entirely) to Medicare Part B. In fact, "there are well over 100 pages of codes," she says. So don't assume you can only submit E/M claims for Part A Stay SNF patients to Medicare Part B.
 
File 3 applies only to ambulance services, and file 4 applies only to those services rendered to beneficiaries in a Part B noncovered stay. The file includes the therapy codes subject to consolidated billing for these Part B noncovered-stay beneficiaries. The carrier must submit claims for the listed services entirely to the SNF. Most urologists will not be involved in using codes from these latter two files.