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Does opting out of Medicare affect locum tenens billing?

Urology Times JournalVol. 47 No. 1
Volume 47
Issue 1

Ray Painter, MD, and Mark Painter also answer questions regarding BCG instillation and reporting of simple laparoscopic prostatectomy.

My private practice is part time, and I have opted out of all private payers, remaining only in Medicare. However, I am thinking of opting out of Medicare as well. I also do locum tenens work, but the hospital does all the billing and I receive nothing from CMS, so I’m assuming my services are billed through the hospital. My question: If I opt out of Medicare in my private practice, does it affect any billing from any hospital that I work as a locum?

If you opt out of Medicare, you are required to sign an affidavit in which you agree to a number of specific conditions, including:

“State that physician/practitioner will not submit a claim to Medicare for any service furnished to a Medicare beneficiary during opt out period, nor will physician/practitioner permit any entity acting on his/her behalf to submit a claim to Medicare for services furnished to a Medicare beneficiary, except for emergency and urgent care services provided to a Medicare beneficiary with whom he/she has not signed a private contract.”

We provide two general situations for consideration. 

Situation 1. You are providing urology services to patients of the hospital during specified periods on an intermittent basis throughout the year. When you are not in town, there is either no urologist in town or there is another urologist who is also providing coverage as you do on an intermittent basis. In short, you are providing urology services to the patient population on behalf of the hospital, but not covering for another physician.

If you opt out of Medicare, Medicare will not pay for any service reported under your National Provider Identifier (NPI). Under this scenario, it would appear that the hospital is reporting your services to Medicare and receives payment for those services under your NPI as the rendering provider. The hospital would not be able to bill for your services.

However, Medicare would continue to pay the hospital for any services you have ordered and services the hospital provided, such as hospitalizations, OR time, imaging, lab studies etc., if you have supplied your Social Security number and NPI on the optout affidavit.

Also by Ray Painter, MD, and Mark Painter -Medicare final rule: How E/M changes help urologists

Situation 2. You are providing services to an area that is normally served by a physician for whom you are being hired for a period of less than 60 days to cover for. (This period can be longer if the “regular” physician has been called to active duty military service.)

This situation is a bit more difficult. We received multiple opinions when researching this situation.

Opinion 1. An optout physician was not precluded from billing under a contracted arrangement in which the physician was paid solely on time worked and services were reported with modifier –Q5 appended to the service with the regular provider’s NPI as the rendering physician. The regular provider is required to maintain a record of the covering physician’s NPI and credentials.

Opinion 2. The optout provider status would continue to pose a problem, as the affidavit prohibits billing Medicare for any services provided.

In the end, we encourage you to seek legal opinion in your state for you and your potential employer before opting out. We would also encourage you to consider first moving to “non-par” (non-participating) status with Medicare for at least 1 year as a transition to optout status. As a non-par provider, you bill your patients directly for all services, and you can either ask the patient to bill Medicare or bill for the patient and the patient would receive payment from Medicare.

As a non-par provider, you are limited to a charge of 109% of Medicare allowed amount and must follow Medicare rules. The non-par status does, however, start you down the path to opting out of Medicare and will not affect your status with the hospital. Your contracting entity, hospital or other, could except assignment on any patient, but would be paid 5% less then if you were a participating Medicare provider.

Next:Billing for BCG instillationMy dad recently started bacillus Calmette-Guérin infusion therapy for his bladder cancer. He goes to his urologist’s office to get the catheter inserted by a nurse and then to the local hospital’s infusion center for the administration of the drug. He is on his second treatment. He recently got a bill for $200. It appears the hospital is billing his insurance a “surgical procedure” every time he goes in for an infusion. There is no surgical procedure. There is an injection into the catheter. No physician is present. I’m so baffled by this billing code. Can you please tell me how this procedure should be properly billed?

The correct CPT code for the instillation of BCG is 51720 (Bladder instillation of anticarcinogenic agent [including retention time]). And although there is no incision or anesthesia-what we typically think of as a surgical procedure-the service has been assigned a code within the surgical section of CPT and is assigned a global period that is treated by payers and physicians alike as a “surgical” service. The hospital charge/payment is based on a formula that allows the hospital to include typical supplies (whether or not they are used), personnel costs, and general overhead. The charge is based on the CPT code for the service and is often labeled as a surgical charge.

Read: How to bill for hospital consults without physical exam

Therefore, the reporting is at least partially accurate. The hospital should also report the BCG as a separate charge under code J9031.

Based on your description of the services, we would project the hospital charges to be as follows: 51720 and J9031.

The amount of charge and reimbursement would vary.

Also see - Beware of these 3 common ICD-10 mistakes

The answer provided here should apply to your situation, particularly if the physician is employed by the hospital in the hospital is billing for all services. However, if the physician is not employed by the hospital, you may receive an additional charge for the insertion of the catheter. That code may vary based on the arrangements between the physician and the hospital.

Next:Reporting a simple laparoscopic prostatectomyWhat is the correct way to report a simple laparoscopic prostatectomy? I was told to use the appropriate open code, but my compliance department tells me I should use the unlisted code. We have agreed to report based on your answer.

First, we will start with the obvious. There is no specific code for a simple laparoscopic prostatectomy. Therefore, using an unlisted code would not be inappropriate. That being said, we also think you have the option of using the appropriate open code.

We will share with you our reasoning.

The codes currently used to report open prostatectomy-55831 (Prostatectomy [including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy]; retropubic, subtotal) and 55821 (Prostatectomy [including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy]; suprapubic, subtotal)-do not specifically include that they have to be performed by an “open” procedure nor do they exclude the use of a laparoscope. The approach, open or laparoscopic, is not designated. Therefore, the codes could be used to report either approach.

Read: Can you bill a urethral suspension with radical prostatectomy?


To add to the comfort of that decision, the AUA, in a Policy & Advocacy Brief, published the suggested coding as recommended by the AUA Coding and Reimbursement Committee. They recommended using the appropriate code 55831 or 55821 for the reasons stated above. AUA officials cannot set payment policy for CMS, but their opinions have a lot of influence. If you follow their advice, you will be safe from fraudulent billing claims, even though a payer may not agree with the recommendation.

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

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