Billing for urology supplies: Rules may vary by payer

March 1, 2010

When it comes to Medicare, supplies are included for all services provided in the office setting.

Q: Can doctors charge for supplies in the office? If the answer is yes, can they discount or decide not to charge under special circumstances, even when a valid Healthcare Common Procedure Coding System (HCPCS) supply code exists?

You cannot charge patients outside of the Medicare program less than you charge other patients. This should not be a problem in most cases; however, calculating what a combination of codes would equal in one coding system versus the total allowable charge in another system is often difficult and time consuming.

Ultimately, as long as you are above Medicare rates and are allowed to bill for supplies, you may be able to charge separately and at a price you choose for any supplies used or provided.

When it comes to discounting or not charging for supplies, you will need to develop some consistency and a process that can be administered within your office. Bear in mind that although many insurance companies are now basing payments on Medicare rates, they still take into consideration your office charges when determining payment. Therefore, you should consider developing your policies first by payer, with a charge or do-not-charge directive for supplies. Consider as well when and why you will charge less for supplies billed routinely to any given payer. Your profile may not be affected by not reporting supplies; therefore, many offices will wisely choose not to charge for supplies instead of discounting them.

The last consideration you will need to make is the effect on your reputation in the community if you charge patients differently. As health care continues to change and the patient's portion of the bill increases, your charging practices will become more of an issue with patients.

Q: I have a question regarding the article "Urodynamics: Accurate billing may up reimbursement" (Urology Times, April 1, 2009). We have a situation where a physician sends a patient to us for urodynamics testing. Our technician performs the testing, and our urologist interprets the results and gives this information to the referring doctor. The patient returns to the referring doctor's office, where that physician discusses the results with the patient and determines a plan of care. How would each doctor bill for these services? We have a similar situation where a provider inside our clinic (original provider) has our technician perform urodynamics testing and then another provider within our clinic interprets the results and gives the information to the original provider, who then has an office visit with the patient to discuss the results and determine a plan of care. How would these services be billed?

A: In the first example, if the physician or other qualified provider who oversees the performance of the test is different from the urologist who reads the test, the billing is split for technical and professional components. The provider performing or supervising the provision of the test would bill the codes provided with a –TC. The provider who reads the test would bill the same codes with modifier –26. This urologist would have to develop a written report that is sent to the second physician in order to document and support the –26 for the codes.

If the urologist who oversees the test provision also reads the test the same day, you would charge the codes once, without modifiers –TC or –26.

If the test is provided in your office under the "supervision" of one physician on one day, the technical component (–TC) would be billed by the "supervising" provider. The second interpreting physician documenting the interpretation of the report on a separate day would bill the professional component (–26).

The provider visit with the patient would be billed under an evaluation and management code, with the review of the interpretation included in the medical decision making for the visit. A modifier –25 must be appended to the office visit provided on the same day as the professional interpretation of the urodynamics test.

Disclaimer: 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.

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