Urology Coding Alert

Question: A patient who is in a skilled nursing facility came to the office for a TRUS, an ultrasonic examination of the prostate, (76872), and a post voiding residual urine (PVRU, 51798). The patient has Pacificare Secure Horizons Medicare replacement insurance. Do I bill all codes at full charge to this insurance carrier or do I bill codes with modifier 26 to the insurance and those with modifier TC to the SNF? Or do the modifier 26 codes go to Medicare Part B and the TC modified codes go to the SNF?

Answer: If the skilled nursing facility (SNF) patient has a Medicare replacement insurance plan, in general, you should bill just as you would bill for Medicare, but even before billing check that the patient indeed occupies a skilled nursing bed and check with the particular carrier how they wish you to bill for a SNF patient when seen in an office setting.

Suggested coding: In general, you would report 76872 (Ultrasound, transrectal) with modifier 26 (Professional component) and 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) without a modifier to the insurance carrier. Code 51798 does not accept modifier 26 or modifier TC (Technical component).

You should directly bill the technical portion of the service -- 76872-TC -- to the SNF.

Here's why: A patient's nursing facility (NF) status will determine how you should bill for your physician's office services. Because Medicare Part A typically covers fully skilled nursing facility patients and consolidated billing rules apply, you can only report a certain number of services to Medicare Part B for reimbursement. When a patient visits your office and is in a covered Part A stay (a skilled nursing bed), the facility is always liable for the payment of the technical components of a service. These services include medications, lab work, x-rays (the technical portion, not the interpretation), the technical portion of EKGs, billable supplies, DME dispensed from the office, etc.

As a result, if the patient is currently in the nursing facility covered under a Medicare Part A stay, the physician can onlybill Medicare Part B for his "professional" services. Any technical services the urologist performs during an office visit must be billed directly to the nursing facility, requesting reimbursement for billable supplies and/or technical component expenses your practice may have incurred during the encounter.

Remember that straight Medicare Part B does not cover nonskilled nursing home charges. On the other hand, Medicaid will cover nursing home confinement.