Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and Reimbursement Sourcebook.

Ray Painter, MD

Q When instilling an agent into the bladder via temporary catheter, can one charge for the in-and-out catheter (51701) as well as the lavage (51700)? An example would be giving a pentosan polysulfate (Elmiron) cocktail for the treatment of interstitial cystitis or administering bacillus Calmette-Guérin (BCG [TheraCys, TICE BCG]) for treatment of bladder cancer.

In the second example you provide, the BCG instillation should be coded as 51720-Bladder instillation of anticarcinogenic agent (including retention time). Again, code 51701 is bundled into the 51720 and unbundling is never allowed. Like code 51700, the CPT inference would require the use of a catheter to instill the anticarcenogenic agent. 

In short, you should not bill the 51701 with either 51700 or 51720 to any payer if the service you are providing that day is solely the instillation of a substance in the bladder. Make sure that you are coding correctly for the instillation based on the type of drug you are using and charge separately for the drugs that are instilled. 

Q How would you code for cystoscopy with instillation of bupivacaine (Marcaine, Sensorcaine) and gentamicin (Garamycin, Gentak) into the bladder and trigger point injection with a mixture of triamcinolone (Kenalog), bupivacaine, and onabotulinumtoxinA (Botox)? (Editor's note: This question is based on an operative note and has been edited for length.)

 First, we will address the cystoscopy with instillation of the bupivacaine and gentamicin. The operative note indicates that a complete diagnostic cystoscopy with inspection of the bladder was performed. "After this was completed, a rigid cystoscope was assembled, lubricated, and placed through the urethra into the urinary bladder in atraumatic fashion. A survey of the entire bladder was performed. The patient's old scar in the left lateral wall of her bladder was identified. There were no other abnormalities in her bladder. Her bilateral ureteral orifices were orthotopic position. The bladder was then emptied." 

The operative note also indicates: "A mixture of bupivacaine and gentamicin was then instilled into the bladder through the cystoscope." Unfortunately, there is no code that reflects both a cystoscopy and instillation. Of course, a code for instillation, 51700, is available (see related question above). The 51700 code does not specify that the delivery device must be a catheter, and code 52000-Cystourethroscopy (separate procedure) does not include reference to an instillation of any type. The operative note indicates that the diagnostic and therapeutic portions of the procedure were separate. Therefore, we would recommend coding both the 52000 and the 51700-59 for this portion of the procedure. 

The other part of the procedure indicates injection of triamcinolone and bupivacaine into three separate injection sites: at 4 o'clock and 7 o'clock of the levator ani and into the left thigh. This was then followed by injection of onabotulinumtoxinA into the same three areas. 

The procedure description in the introduction of the operative notes lists the injections as trigger point injections. However, the body of the operative note references the location of each injection. We would encourage any operative note to be clearly descriptive and match the other parts of the operative note, such as findings and procedures performed in detail. In other words, all introductory parts of the note are considered a summary for which the body of the note should provide matching detail. 

As such, we would recommend the trigger point injection code 20552 for all injections. Trigger point injections are covered under LCD restrictions for multiple jurisdictions and should be reviewed prior to reporting, making certain that supported diagnoses for muscle spasms are clearly indicated in the patient's medical record. 

Coverage of triamcinolone, bupivacaine, and onabotulinumtoxinA in this instance is not the concern of the office, as the service was provided under general anesthesia in facility that would be paid separately for the drugs used. If provided in an office setting, triamcinolone and bupivacaine can be reported under HCPCS codes if trigger point injections are covered. OnabotulinumtoxinA is a separate issue covered in many states for the treatment of muscle spasms, but not in all areas. The LCD for onabotulinumtoxinA will also need to checked if billed in the office setting. 

Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o  

Questions of general interest will be chosen for publication. 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. 

, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of 

Urology Coding and Reimbursement Sourcebook

Articles

Make sure that you are coding correctly for the instillation based on the type of drug you are using and charge separately for the drugs that are instilled.

Urologists should avoid unbundling instillation, in/out catheter

This means that "community rating" for all health insurance policies, also a mandate in the law, is feasible and will be implemented. 

There was one significant strike-down by the court that may, in some states, impact the implementation of coverage for those with low income. The court ruled that the federal government cannot force the states into expanding Medicaid coverage by withholding current Medicaid funding if they do not expand as directed by the law. However, it does not prevent the feds from "enticing" states to participate in the expanded Medicaid coverage programs; they just cannot cut off other Medicaid funds if states choose not to participate. Many states will likely proceed with some form of Medicaid expansion to acquire the extra funds available. 

All the other aspects of the bill are now the law with no changes. Entities such as medical homes, accountable care organizations (ACOs), and the Independent Payment Advisory Board (IPAB), among others, will remain unchanged. 

What does this all mean to the practicing urologist? Here is an overview of what to expect in the months and years ahead. 

Implementation of health insurance exchanges in the states. 

The mandate requires health exchanges to be set up in each state, allowing consumers to compare products. The federal government could take charge in setting up the health insurance marketplaces if the states refuse to do so. It is expected that individuals and small businesses will be able to use the exchanges to shop for insurance. Patients who have not been able to afford insurance because of pre-existing diseases will be able to buy insurance through the exchange. Once implemented, this will mean that your office will need to be vigilant in checking patient coverage for each visit, as some patients will change insurers for better pricing. Additionally, you may see more aggressive contracting from payers for your services. Know your place in the market and prepare to negotiate. 

States will play a key role in delivering new health insurance coverage to millions of lower- and middle-class people. However, many states have resisted, and the National Association of Insurance Commissioners expects only about half the states to be ready to set up new health insurance markets, slated to open for business in 2014. Some states have already implemented changes. Expect the implementation to vary from state to state. You can expect to receive payments for more patients, at Medicaid rates. 

The court's ruling upheld the mandate of coverage for millions of uninsured Americans. The "experts" who have predicted how many Americans will have to pay the tax for not purchasing health insurance disagree over the actual number. However, most expect an uptick in the number of people with insurance. 

Community rating for all private insurance policies. 

The law's requirement that most people buy insurance or pay a penalty if they fail to obtain coverage has been reported to be the essential trade-off the insurance industry sought in exchange for the law's requirement that coverage be offered to people with pre-existing health conditions. 

What does this all mean to the practicing urologist? Here is an overview of what to expect in the months and years ahead.

With health care reform upheld, expect these big changes

Q Urodynamics continues to be a tremendous challenge for our coders. Can you provide information on what is expected in terms of documentation to identify the actual study components performed? What would an auditor be looking for (graphs and summary report, interpretation, procedure write-up by the tech)? Common practice for our group is to have the studies performed on a separate date by a tech, with a future reading/interpretation by the physician. Is correct practice to split these services in this case? Should there also be a brief procedure description by the tech when the studies are performed? 

As far as split billing, it is accurate to report the services provided on the date the service was actually provided. Therefore, your circumstance where the technical component is provided on a different day than the procedural component should be billed as technical component on the day performed (code with modifier –TC) and professional component on the day read (code with modifier –26) on a different day. If the payer requires global billing (billing of the codes with no modifier), we recommend you obtain that directive from the payer in writing. 

In a recent audit of urodynamics charges, Medicare recognized some codes but not others, and the documentation for all services that were reviewed only included the report from the urodynamics machine. This review pointed out the lack of understanding of these codes by payers and physicians.

Coding for urodynamics presents tough challenges

As we have analyzed practices across the country over the past year, a common theme has emerged: The organized practice, with clearly defined roles for each member, is the most efficient and profitable. Consistent and strong leadership is common among these successful practices; however, a clear structure and protocol have also proven invaluable during any change in leadership. Based on these experiences, it is clear that the best practices incorporate written structure and protocols, with measurable review standards that can be understood and implemented by all within the practice. 

Devoting time to business side crucial 							

Here are the top three areas in your practice that you can influence. Regardless of practice type, each provider and employee needs to understand each of these: 

 Who is capable of implementing systemic change within your practice? In short, the management structure should be clearly defined. As issues are identified, this person or group will need to be able to make a decision and follow through with an implementation program. 

Analyze your current administrative structure. Are decisions made fairly and efficiently? If decisions are consistently deferred, a restructuring of the process should be undertaken. Ownership has the power to change this structure. Egos and politics should be taken into account; however, logic and data should dictate direction. 

Have there been multiple changes in administration? If the leadership of the management team has changed frequently, the practice must realistically determine whether the issue is the ownership and employees or the hiring process. One or the other is usually at fault; of course, illness and competitive hiring in the area can also play significant roles. Be objective and make changes accordingly. 

Does the current management have the core capabilities required for the job? Often, physician practices promote from within. Loyalty is a valuable asset and should not be discounted. However, an office manager for a small group may not have the training or skills to manage a large group. Develop a job description as if you were going to hire a new person and compare the qualifications of your current manager against the list. 

 As a health care provider, your life can be made more stressful if you are trying to adjust to a set of values that you do not agree with in principle. Understand that with any group, it is next to impossible to align the group with the individuals 100% of the time. If everyone at least understands the core values, however, the individuals can choose either to adapt or leave the group. 

It is important to be able to adapt. No group or individual can remain entrenched in a particular value set with the changes that are pressuring the business of health care. Intrinsic growth of an entity will also foster change in values. Many large urology groups were formed with the promise of little or no change to the groups that were merged; however, as the utilization of health care has declined recently, many of these groups are being forced to make changes to the smaller groups to cut costs and take advantage of the new, larger entity. A "growing pain" such as this is expected and needed for the health of the group. 

 Regardless of the shape or the structure of a practice, the heart and soul of the revenue stream is coding for services rendered. Without clear involvement and a coordinated team effort, you will lose money. 

As the provider of services, the clinical staff is the only group capable of documenting and coding the services rendered with any accuracy. We have all seen groups in which the providers simply document services they provide and allow others to code and bill. With electronic health record systems, codes are increasingly driven by the templates chosen for documentation. In either case, the clinical service provider must understand the coding outcomes in order for the documentation to accurately reflect the services rendered. In the case of the EHR, if the appropriate template is not selected, the codes sent to the billing program will not reflect what has been done. 

Ultimately, it is the responsibility of the service provider (physician) to correctly code for the services rendered. Therefore, it is recommended that the practice train the clinician on coding, develop and maintain tools for these individuals, and measure coding through compliance reviews on a regular basis. 

Coding issues: Administrative staff's role 							

 The administrative staff in charge of processing charges and payments must be provided the tools and training to bill each payer by their rules and to appeal claims that are incorrectly paid. The staff must actively research coding issues and receive regular training to keep up with changes. Additionally, it should be tasked within the system to provide feedback to the providers and other staff members relative to write-offs, denials, and other actions that affect payment. This can prevent unneeded losses from the provision of services that are not contractually allowed. 

Efficiency is key and can be measured, but be careful. A squeaky-clean accounts receivable may not be indicative of excellent collections but can instead reflect an efficient but costly write-off policy. Systems should be set and maintained that constantly question charges and payments within the practice. Staff members should expect to be questioned. 

These are only a few of the issues that can be addressed by physicians to make life easier. Hope is not a business strategy. Change is not the enemy. The business of medicine can be tamed so that the clinical work you became a physician to provide can remain your primary focus. 

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.

There are many aspects of the business of medicine that are difficult to influence. Here are some ways that you can have some control.

Ray Painter, MD

Articles

Urologists should avoid unbundling instillation, in/out catheter

With health care reform upheld, expect these big changes

Coding for urodynamics presents tough challenges

Urology practice success: Control what you can control