Urology Coding Alert

‘Coding for dollars’ could have you paying a bigger price later.

It’s a scenario every coder has encountered: your provider performs a procedure that isn’t specifically tied to a particular CPT® code, although another code descriptor almost matches the service. Sometimes you’re justified in appending a modifier such as 52 (Reduced services) and explaining the situation to the payer. At other times, that approach won’t work. And in still other situations you believe the codes you are told to submit are incorrect.

What’s a coder to do?

Test Yourself with a Real-world Case

Consider this scenario from a Urology Coding Alert reader who asked for advice in handling situations with incorrect billing.

Question: I work in the office for a urologist who also performs laparoscopic procedures. When he assists other urologists during laparoscopic procedures, we obtain the billing information from the other urologists’ coders so we can bill our urologist’s service as the assistant surgeon.

Sometimes there is incorrect billing pertaining to the CPT^® codes and diagnosis codes billed, according to the documentation from the operative report. We will contact the other office and ask them to verify the codes and correct if necessary, but corrections are not always made.

In an effort to get the claim submitted in a timely matter I have submitted the claim for my doctor as the assistant. I have done it in two ways: 1) submitted as billed by the other office and urologist, making notes on the account for the errors/problems and 2) submitting the claim with the correct billing information.

What is the correct way to handle this problem?

Answer: You should never knowingly send in the wrong codes just to get paid. That is a clear coding and compliance violation.

Your practice of contacting the other surgeon’s coder and trying to explain why you will be submitting different coding is a good start. If they don’t agree or follow through with the proper coding, however, you should still submit the codes you believe are correct.

“I encountered this all of the time when I had my billing company,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare in Tinton Falls, New Jersey. “I, like the writer, would contact the primary surgeon and tell them that they coded the case incorrectly and tell them how it should be coded and why. Most often, they do not listen or agree with me ... they submit the claim their way. But I will not submit the wrong coding for my doctor. That is a compliance violation,” she adds.

Tip: Send an email to the lead urologist’s practice explaining the codes you will be submitting and why. This ensures you have your contact with the other coder in writing, and shows you informed them that you intended to submit different codes.

“You won’t likely know what the other urologist ends up submitting or if they get paid, but it’s not really your concern,” Cobuzzi explains. “As long as you are compliant and bringing in the reimbursement your surgeon deserves, you’re doing your job correctly.”

Warning: Getting paid might be a bit more challenging when the other urologist is submitting different codes. You may need to appeal a denial that results from both urologists submitting different codes, but during the appeal process, if your coding is correct, you should get paid.

“We got paid,” Cobuzzi says. “Not always the first pass; sometimes it required sending in the documentation with an appeal. I would appeal with my documentation and show that my coding was correct.”

Bottom line: You should always code correctly and avoid knowingly submitting an incorrect claim just to match the other urologist’s billing. “If you think about it, when there is an assistant surgeon, there are three sets of codes the payer gets: the primary surgeon, the assistant surgeon, and the facility and not all three are always in sync,” Cobuzzi says. “Facilities and surgeons don’t discuss the coding and usually don’t work together to make sure they have the same outcome. Each independently codes the case. Why shouldn’t the assistant surgeon do the same, in particular if they have a highly qualified coder.”