Urology Coding Alert

Reversal of some schedule changes could be good for your practice.

Code updates aren’t the only changes you have to master every year. There is a slew of general reimbursement news to review to keep your practice’s reimbursement flowing in 2016. Take a look at the issues facing urology practices for next year. 

Rejoice Over Stalled Incident-To Changes

According to experts, despite previous indications, incident-to rules remain unchanged for 2016, in that a urologist who initiates a patient’s care at an initial visit may be in the office when a non-physician practitioner (NPP) sees his patient during another separate encounter. The practice can then bill the service incident to the physician, under the urologist’s national provider identifier (NPI), for 100 percent reimbursement. To bill incident-to, the physician supervising the incident-to service does not have to be the same one who originally saw the patient.

Important: This reverses a rule change that would have gone into effect on Jan. 1, 2016, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook. “This reversal of the rule change means more NPPs can bill incident-to services directly to Medicare at 100 percent reimbursement when any physician is in the office suite,” he adds.

Ferragamo points to Health Law Update’s (Baker Hostetler) recent article “ Proposed Rule Aims to Reduce Stark Regulations and Clarify ‘Incident To,’” which states “... we are aware of communication from CMS after the proposed rule was published indicating that the revisions were intended to clarify that the ordering and supervising physician/NPP do not need to be the same person. Stakeholders are encouraged to submit comments on this issue to ensure that the regulations accurately capture CMS’s intended policy.”

Background: In the July 15 proposed Medicare Physician Fee Schedule (MPFS), CMS suggested paying for incident-to services only if the doctor who bills for the incident-to service is the same person directly supervising the care.

“To be certain that the incident to services furnished to a beneficiary are in fact an integral, although incidental, part of the physician’s or other practitioner’s personal professional service that is billed to Medicare, we believe that the physician or other practitioner who bills for the incident to service must also be the physician or other practitioner who directly supervises the service,” CMS said in the proposed rule.

Still relevant: CMS also proposed that the person providing the incident-to service does so in accordance with state law and is licensed to do it. The incident-to provider also cannot have been excluded from any federal health care program or have had their enrollment revoked for any reason. In other words, just because the service is billed under a supervising doctor’s number doesn’t mean the performing NPP can be excluded from Medicare. These guidelines will still apply, even though the supervision changes did not go through.

More details: You can ead the article from Health Law Update at www.bakerhealthlawupdate.com/2015/07/proposed-rule-aims-to-refine-stark-regulations-and-clarify-incident-to.

Stay Tuned for Revaluations

“There are potentially mis-valued urology codes that CPT^® and the update relative value unit advisory committee (RVUAC) will reexamine and make fee recommendations some time by 2017,” Ferragamo says. “The urology codes to be reviewed account for the majority of urology spending under the physician fee schedule with allowed Medicare charges over $10,000,000.”

Expect review and revaluations of the following codes that represent services your urologist likely performs:

• Skin biopsy code 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion)
• Bladder irrigation code 51700 (Bladder irrigation, simple, lavage and/or instillation)
• Indwelling catheter insertion code 51702 (Insertion of temporary indwelling bladder catheter; simple [eg, Foley])
• Bladder instillation code 51720 (Bladder instillation of anticarcinogenic agent [including retention time])
• Complex cystometrogram (CMG) codes 51728 (Complex cystometrogram [ie, calibrated electronic equipment]; with voiding pressure studies [ie, bladder voiding pressure], any technique) and 51729 (... and urethral pressure profile studies [ie, urethral closure pressure profile], any technique)
• Electromyography (EMG) studies code 51784 (Electromyography studies [EMG] of anal or urethral sphincter, other than needle, any technique)
• Urodynamics codes 51797 (Voiding pressure studies, intra-abdominal [ie, rectal, gastric, intraperitoneal] [List separately in addition to code for primary procedure]) and 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging)
• Cystoscopy code 52000 (Cystourethroscopy [separate procedure])
• Prostate biopsy code 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach). 

Be prepared: You may see less pay for laparoscopic lymphadenectomy procedures your urologist performs as well. There will be a wait and see period during which, Ferragamo says, the following procedures may undergo reduction in their work RVUs for 2016:

• Laparoscopic node biopsy code 38570 (Laparoscopy, surgical; with retroperitoneal lymph node sampling [biopsy], single or multiple)
• Laparoscopic bilateral pelvic node resection code 38571 (...with bilateral total pelvic lymphadenectomy)
• Laparoscopic bilateral extended pelvic node resection code (...with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling [biopsy], single or multiple).

Don’t Write Off Global Periods

At the end of 2014, CMS put forth a proposal in the Federal Register that shocked many coding professionals. Under the plan, the current 10-day global codes would transition to 0-day in 2017, and the 90-day global codes will change to 0-day in 2018. “This certainly would have resulted in a pay cut for surgeons,” Ferragamo says.

Update: The Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) reversed the decision of CMS to eliminate bundled payments for 10- and 90-day global surgical procedures.

 “It’s hard to say definitively if the removal of global period would be good or bad for physicians as I think there are good and bad aspects,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with Peace Health in Vancouver, Wash. “Certainly the potential is there for surgeons to make more money, especially for patients who are very sick and require move follow up or for patients who develop complications. At this time, Medicare bundles all of that.” On the other hand, Bucknam says surgeons would need to change their thinking and their documentation, improving the details they include, for post-operative visits or face drastic reductions in reimbursement.

Change may still come: “Unfortunately, we will likely see this pay cut in global payments in the near future,” Ferragamo says.

Bucknam agrees: “I do think that CMS will eventually eliminate global periods one way or the other,” she says. “Consider the proposals to bundle payments for hospital care. Hospitals do not have global period for surgery. That is particularly for physicians. If payments are bundled I think it is likely the global period concept will not apply. There are also some other new payment methodologies that are being tossed about that would work much better if a global period wasn’t part of the equation.”