Q. How do you appeal a denied Medicare claim?
A. If the payer has a standard appeal form, fill out the Medicare appeal form and resubmit it with a copy of the original claims form, Medicare EOB, correct coding edits, and any other supporting documentation that proves the codes should be paid.
If the payer does not have a form, draft a letter stating all the reasons why the claim should be paid according to guidelines and provide proper contact information. In addition, all supporting documentation should be attached.
Certain states have a telephone appeal line where all appeals need to originate. Many Medicare appeal departments have a specific address that all appeals must be processed through.
If the claim is denied by the Medicare appeals department, and the intent is to continue the process of getting the claim paid, state- and payer-specific guidelines must be followed to elevate the appeal to a higher level.
Q. How should I bill when the physician performs a potassium sensitivity test?
A. There is no specific code for the potassium sensitivity test. However, since the test includes the instillation of a drug, then 51700 (bladder irrigation, simple, lavage, and/or instillation) should be used. In addition, you would use the appropriate J code for potassium chloride solution (J3480).
You would also charge an E&M code if there was a significant and separate E&M service provided, for example, a consult or a discussion on the disease process and the treatment of the disease process following the test. Of course, if an E&M visit is charged, the –25 modifier should be attached.
Q. Does code 52352 cover the retrograde pyelogram and ureteral catheter placement?
A. That depends. The CPT book definition for Code 52352 is: "Cystoscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)." So, this procedure includes the insertion of a ureteral catheter, insertion of stent, or installation of contrast media if it is used to facilitate the procedure. In this case, all would be covered with the same code.
However, if you were to have scheduled the patient for a diagnostic retrograde, and the diagnostic retrograde led to the diagnosis of the calculus and you proceeded with the 52352, then you should be paid separately for the diagnostic retrograde, 52005.
Unfortunately, it is bundled, and it can never be unbundled. Therefore, you will be denied. However, some payers, upon appeal, will pay, as they appropriately should.
In addition, if the physician inserts an indwelling stent following the procedure, to be left in for removal at a separate setting (52332), then charge 52332 in addition to the 52352. This is bundled, but can be removed with a modifier, and if charged, the –59 modifier should be attached.
This is completely appropriate since the AMA and AUA have determined that an indwelling stent is not a component or an integral part of the ureteroscopy procedure, and if inserted, should be charged separately.
Q. We have confirmed with hospitals that they are billing each component of a urodynamics study (CPTs 51726, 51784, 51795, 51797 and 51741) with modifier TC (technical component). In turn, after one of our physicians interprets the urodynamics results and documents the findings in our patient's medical record, we bill each component with modifier –26. Do you recommend reducing the standard fee for each CPT code billed with modifier –26? Or should we bill full fee for each and let the insurance company determine the reduction?
A. If you have a contract with the insurance company that pays you a set fee for each service performed, such as Medicare, I would continue to bill the full fee for the service and let the payer reduce your fee. However, if this is a patient who's paying his or her own fees, or if this is an insurance company with which you do not have a contract, then you should reduce your fee to the amount that you should expect to be appropriately paid for your services. That would also prevent patients with their own medical savings account from having to pay the full fee out of their pocket. They do not have the edits to monitor the charges; therefore, you should be fair in your charges to those people.
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The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
Q. How do I charge for a patient sent from a nursing home for a consult who, upon evaluation, required a cystoscopy? A. For a routine nursing home patient, charge the appropriate level of outpatient consult with a –25 modifier, charge for the cystoscopy (52000), indicate the place of service as "office," and you will be paid as you would for any other office visit. If the patient is in the first 100 days of discharge from the hospital and Medicare is paying the bill through Medicare Part A to a skilled nursing facility (SNF), E&M services are paid as outpatient services in your office without a problem. However, any "procedure" will be paid as if it were performed in a facility, or a "facility fee." Any service you provide with a technical component and a professional component will only be paid for the professional component. Most important, drugs normally paid by Medicare Part B will not be paid by Medicare Part B when given to SNF patients. You should have a contract with the nursing home to pay for these services because the SNFs are paid on the diagnosis related group (DRG) concept similar to a hospital. Any unpaid medications, the difference between procedures paid at the facility fee and non-facility fee, and unpaid technical fees should be paid by the nursing facility if you have the appropriate contract. Q. I work in an office with six physicians. We've set up an operative suite and are considering doing a photoselective vaporization of the prostate (PVP) laser procedure for BPH as an outpatient procedure in the office. We arranged for the anesthesia and all the safety equipment that is required. How do we bill for the procedure, and what will we be paid? A. I have good news to report. Last year physicians used 52647, which paid both a facility fee for a procedure performed in the hospital in addition to a non-facility fee for a procedure performed in the office or other outpatient setting. A change in the terminology on the laser codes in CPT prevented 52647 from being used to report the PVP procedure as of January 1, 2006. As of this date, therefore, 52648 is the only correct code to use. The good news came in a recent press release from PVP device maker Laserscope, which stated: "The correct way to code the laser as an outpatient or inpatient is to use the 52648 in place of service, and the national average payment will be approximately $3,100 for the outpatient procedure and approximately $600 for the procedure if in the hospital." So, CMS has finally agreed to pay the non-facility fee for the 52648 code as of the beginning of 2006. The new payment rule will apply to all laser treatments of the prostate that are described by that code. Q. There are a number of different LHRH products now available on the market (both injections and implants). In the case of a Medicare patient who has no preference between an injection and an implant, is there any financial advantage of using one drug over the other? A. The answer to your question depends on your contract for the drug. There are several issues to consider. First, consider the spread between the cost of the drug and the payment you will receive from Medicare. Obviously, if you're using a three-month drug, that profit will occur four times a year, whereas an implant provides a once-a-year profit. The other variables to consider are drug administration income, office expenses, and time. E&M visits should not enter into the equation. The Centers for Medicare & Medicaid Services has made it clear that you should only charge for an E&M visit when it is medically necessary. Theoretically, the number of visits should not vary with the injection vs. the implant. The patient should be seen when medically necessary. Take the injection fee for the drug and subtract the cost for that encounter, and multiply by the number of injections per year. Be sure to compare that profit to the implant fee minus the procedure cost for the yearly implantation. Another key issue is the physician's time. The doctor usually performs the implantation, whereas a nurse or medical assistant administers the injection. If the injection is chosen, the physician could use that time to see other patients. Once you add these factors together, you'll have your answer.
Q. When doing ultrasound of the prostate alone or with a biopsy in the office, can we bill 76872-26, 76872-TC, and 99215?
A. If the urologist owns the equipment and actually performs the procedure, he or she should charge 76872, diagnostic ultrasound of the prostate, without a modifier. The ultrasound can be charged with or without the prostate biopsy when performed.
If the urologist provides a significant E&M service in addition to the procedure, then a separate charge should be made for the level of E&M service provided. For instance, following a diagnostic ultrasound and the discussion of findings, the urologist discusses the disease process and its treatment. In that situation, an E&M service would be appropriate at the level of service provided.
That level can be reached by either components or time. (Refer to the pocket card and wall chart for details.)
There is no set regulation that would allow the charge of a 99215 with a diagnostic ultrasound. Each E&M service that is provided has to be medically necessary, significant, and separate from the procedure performed, and the reporting must accurately reflect services provided.
Q. What is the modifier for retrogrades and renal stents placed in the office under fluoroscopy and local anesthesia? What are the codes we should use?
A. First and foremost, for procedures performed in the office, you would use "office" as the place of service, and you would charge the non-facility fee on the fee schedule. For example, the national Medicare average payment for the non-facility fee for the insertion of the stent is $332.74, while the facility fee is $155.
If the physician performs a diagnostic retrograde (52005) and the insertion of a stent (52332) at the same setting, each should be billed separately. No modifier is needed for Medicare because the two are not bundled. However, if you were billing this to a patient with private insurance, I would apply the-51 modifier to the retrograde, which is the lesser of the two procedures. If a physician reads the retrograde in the office and does not send it out to a radiologist for additional reading, then the physician would also charge the radiographic reading: 74420, urography, retrograde, with or without KUB.
Because the physician owns the equipment and is reading the X-ray, charge it without a modifier. Code 74420 without a modifier pays both for the technical (-TC) and the professional fees (-26).
The fluoroscopy, unfortunately, is bundled into the other codes. If the fluoroscopy is used to facilitate the procedure, then it should not be charged.
Charge for the fluoroscopy only if the fluoroscopy is being conducted for a separate reason. For example, if the physician performed a retrograde and the insertion of the stent on the right kidney and he used the fluoroscopy to evaluate the left kidney for stones, then you would charge fluoroscopy and would pull it out of the bundle by using the modifier-LT for the fluoroscopy and-RT for each of the other procedures.
If the patient was originally scheduled for the insertion of the renal stent and the retrograde was performed to facilitate the insertion of the stent, then you would charge only for the stent insertion.
Q. Is the code 52000 listed as a surgical procedure or a scope code?
A. All codes, including the 10000 series of CPT codes through the 60000 series of procedural codes, are considered surgical procedure codes. That includes all of our 50000 series of urologic codes. Within the surgical procedural codes are codes that are considered endoscopy codes. You will find endoscopy codes under the GI, orthopedic, respiratory, cardiovascular, and GU sections. Cystoscopy (52000) is an endoscopy code. In fact, it is considered the base code for many urologic endoscopy procedures.
I recommend that you visit the AUA Coding Today Web site ( http://www.auacodingtoday.com/) and click on "52000." Under the CPT/HCPCS tab, click on the small tab "national," and you will be given a list of codes considered to be in the same family.
In this case, most of the codes are bundled with a cystoscopy, and cystoscopy cannot be charged separately. However, if you bill any of the other two codes in that family, the second procedure will be paid according to the multiple endoscopy rules. The difference between payment for the procedure performed and the base code will be paid, as opposed to the normal procedural reductions, e.g., 50%.
Q. How do you bill for a cystoscopy, laser lithotripsy of bladder stone, and endoscopy of ureteral intestinal segment with removal of multiple stones when the patient has had a transplant, including a segment of small bowel replacing the distal ureter?
A. This situation presents a very interesting problem with coding. First, a 52318-litholapaxy—crushing or fragmentation of calculus by any means in bladder and removal of fragments complicated or large (over 2.5 cm)—was performed and should be charged.
An endoscopy through a stoma from the bladder into the small intestine was performed, which could be partially coded as 44380, ileoscopy, through stoma, diagnostic, with or without collection of specimens by brushings or washings. Unfortunately, there is no comparable code for removing a foreign body through the ileoscopy. I would suggest using 52320, cystoscopy with removal of ureteral calculus, as your second code.
In this case, the stoma is from the small bowel to the bladder and the bowel is functioning as a ureter.
Therefore, I think you are perfectly correct in using the code. As a bonus, 52320 pays a lot better than 44380.
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