Urology Coding Alert

Knowing which urological services are covered will save you time and money

Do you think that only the billing staff in your office needs to worry about the rules and regulations surrounding skilled nursing facility (SNF) patients? If so, think again, because a patient's SNF status determines how you code your urologist's services.

Leave the Professional Portion to Medicare

Because Medicare Part A typically covers SNF patients and consolidated billing rules apply, you can only report certain codes to Medicare. For instance, CMS regulations state that for services with both a technical and a professional component, you should report only the professional component to Medicare. You should report the professional component to Medicare and then submit a claim to the SNF for the technical component. And for many of the medications your urologist administers, such as Lupron and Zoladex, Medicare Part B will not reimburse you in the usual manner. Instead, you must submit a claim to, and seek payment from, the SNF itself.

"Several of our patients actually come from an SNF, but the problem arises when we find out after the fact that the patient is covered under Medicare Part A," says Jennifer Sikkink, CPC, of urology Specialists in Sioux Falls, S.D. One of the most important questions you can ask a patient is whether she is a resident of an SNF or whether she is from an SNF bed in a nursing facility.

Example: Your urologist sees a patient with bladder cancer and administers a Bacille Calmette-Guerin (BCG) instillation. You're unaware that the patient is an SNF resident, so you report 51720 (Bladder instillation of anticarcinogenic agent [including detention time]) for the drug instillation and J9031 (BCG live [intravesical], per instillation) for the drug itself to the patient's Medicare Part B carrier. If the patient is an SNF resident, covered by Medicare Part A, the carrier will likely deny part of your claim. Medicare Part A will not reimburse your office for the drug, and your urologist will be out $113.57. For an SNF patient in this scenario, you should report the instillation (51720) to the Medicare Part B carrier, and the cost of the medication (J9031) to the SNF.

Urodynamic studies are another example of a common service that your urologist may perform and that require you to report the professional and technical components separately for SNF patients. For example, when your urologist performs a cystometrogram and a leak point pressure test in your office on an SNF patient, report 51725-26 (Simple cystometrogram [CMG]; professional component) and 51795-26 (Voiding pressure studies [VP]; bladder voiding pressure, any technique; professional component) to Medicare Part B. Modifier 26 indicates that you're requesting reimbursement for the professional component. Submit the technical component directly to the SNF.

Note: Don't be surprised if the nursing facility requires a contract due to Medicare Part A requirements. To receive payment for the technical aspects of services your urologist performs on SNF patients, you may need to have a set contract with the SNF.

Part B Covers E/M Services

Medicare Part B will reimburse E/M services that your urologist performs in his office, along with certain procedures such as cystoscopies, says Alice Kater, CPC, coder for Urology Associates of South Bend, Ind. For example, Kater says, "If a Medicare B patient is in an SNF and we see the patient in our office, we would bill Medicare B for the E/M visit, cysto, and catheterization. We would then bill the SNF for the catheter, leg bag, urinalysis, and ultrasound for PVR."

How it works: If your physician performs a level-three in-office visit for a new patient and a cystoscopic examination, you should report 99203 (Office or other outpatient visit for the evaluation and management of a new patient ...) and 52000 (Cystourethroscopy [separate procedure]). Add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99203 to indicate the E/M service was separate from the procedure.

To learn about other urological procedures that are not subject to the SNF consolidated billing and that you can report directly to your Part B Medicare provider, visit www.cms.hhs.gov/medlearn/2004snfannualupdate.asp to view the File 1--Part A Stay--Physician Services file. Be sure to check this list before reporting urological services for SNF patients. You can also visit www.cms.hhs.gov/medlearn/snfcode.asp for additional information.