Coverage agreements: How they affect urology billing

January 1, 2012

Whether a coverage arrangement is in place makes all the difference when seeing another urologist's patients.

Q: Can I charge for hospital visits if I see another urologist's post-surgical patient who is still in the global period (for instance, when they're on call and round on many of these patients)? Or is it considered part of the surgery?

A: As with any new technology, we often have to wait for CPT to adopt new codes that accurately describe the services provided, wait for a value to be assigned that will reimburse for the services, and/or wait for the coverage policies to be adopted. Although the system is designed to follow a step method, we have all seen that coverage and payment may precede the establishment of a code and value.

We did not locate a code or coverage policy that clearly applies to the use of image fusion with prostate biopsy ultrasound guidance. In today's health care environment, coverage, coding, and payment for new technology are not automatic. Any new technology has to demonstrate clinical efficacy supported in peer-reviewed literature and have FDA approval, if applicable, to be included in CPT.

Additionally, with many new technologies, payers are beginning to demand cost efficiency for a new procedure or service before they will cover it. We assume the manufacturer and those interested in the service you are describing are pursuing these goals.

In the short term, the following codes may be applicable to the service you describe:

Without further information on the system and its use, we cannot comment directly on whether the codes above are applicable and/or paid for when using the device.

Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at UT@advanstar.com
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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.

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.