• Benign Prostatic Hyperplasia
  • Hormone Therapy
  • Genomic Testing
  • Next-Generation Imaging
  • UTUC
  • OAB and Incontinence
  • Genitourinary Cancers
  • Kidney Cancer
  • Men's Health
  • Pediatrics
  • Female Urology
  • Sexual Dysfunction
  • Kidney Stones
  • Urologic Surgery
  • Bladder Cancer
  • Benign Conditions
  • Prostate Cancer

Getting paid in 2014: What you need to know


In this column, we outline the issues that we know will be important in 2014 and discuss what we think might be implemented by Medicare for 2014.


Traditionally, in our December article, we outline the issues in the final Medicare fee schedule for the next year. Unfortunately, the government shutdown has delayed publication of the schedule until Nov. 27, 23 days after its normal publication date. Go figure.

Therefore, for this year’s December column, we will shift focus and outline the issues that we know will be important in 2014 and discuss what we think might be implemented by Medicare for 2014.

New CPT code

There is one new CPT code: 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent [eg, Gibbons or double-J type]).

This code was added, as suggested by Medicare, because urologists billed the insertion of an indwelling ureteral stent with ureteroscopy/lithotripsy a high percentage of the time. We do not know the value of the combined code. A strong stance by the AUA may result in a value commensurate with current payments, but we will have to wait and see the Centers for Medicare & Medicaid Services’ final value. When codes are combined, the payment usually decreases.

Affordable Care Act-driven changes

At press time, the Affordable Care Act’s (ACA) personal insurance mandate is moving forward and there are many uncertainties. The rollout of the health care exchanges may multiply the problems we have with patients changing insurance. We think four things are very clear:

The insurance coverage for some of your patients will change on Jan. 1. As of Jan. 1, we recommend that you treat all of your patients as if you have no idea what their insurance coverage is. Reconfirm the eligibility of patients on every visit and verify their coverage for the services your office intends to provide. The insurance company may have changed, or it may just be the policy and/or the coverage that has changed. We won’t go so far as to say that you should throw out all of your insurance data and start anew, but we would recommend that you treat the old data as being suspect and insist that each patient’s insurance information be checked and compared to existing data.

Many of you have been exposed to our “wheel of fortune” (the detailed step-by-step description of documentation, billing, and collection for services in the physician office) and the role that accurate insurance information plays in submitting a clean claim. If you follow best practices in each step of the claims submission process, including collecting from the patient prior to service, then you will receive full payment for services rendered within 10 to 28 days for the majority of services. If a claim is rejected, requiring an appeal, payment from the insurance company will come within 45 to 60 days if at all. In addition, your in-house costs go up astronomically; it’s estimated that the average cost for an appealed claim is $30 to $45. The cost of submitting a clean claim is about $5 or $6. If you do not appeal, the costs are even higher. If you do not collect from the patient up front, your time to collection and write-offs will increase.

Patients will be paying a higher percentage of the total cost. We highly recommend that you fine-tune your patient collection process. Think about the consequences of not having an effective collection process. Using simple math, an average urology practice operating at 50% overhead cost means that a patient on a Bronze ACA plan with a 40% co-pay translates into 80% of physician take-home pay coming from the patient. (This does not include the deductible, which on average has also increased.) Although charity care is a part of every physician practice, you should make that decision prior to providing the service instead of having a non-collectable debt.

The databases, electronic solutions, and know-how are available for you to know/estimate the patient’s responsibility prior to providing a service. This will allow you to collect at the time of service, give a discount, set up a payment plan, or determine that you will provide the service free of charge. It is far cheaper to write a refund check than it is to bill and collect. Data clearly demonstrate that patients not paying after three statements will result in collections of only 10% of charges owed by the patient. If you cannot set this up in your office or don’t understand how to do so, ask for help now. Don’t wait until you have a problem. (Go to our website, www.prsnetwork.com, if you would like more information.)

Coverage for preventive care will increase. This part of the ACA is a double-edged sword. More services that you provide may be paid for by insurance; however, as patients are paying more of the cost for all other services, there may be pressure for you to label services as preventive care when in reality they constitute diagnosis and/or treatment. We strongly encourage you not to bend to patient pressure or the feeling of compassion for the patient. Bill accurately for the services you provide and avoid the audits and risk of “take backs” in the future.

More patients will be eligible for Medicaid. With increased federal subsidies, Medicaid may be a more viable payer in some states but the increase in covered lives will make it difficult for many plans to process the increased numbers. Each practice will have to carefully examine its state Medicaid plan and determine if and how much you are willing to participate in Medicaid in your state.

Continue to Avoid the 2015 PQRS penalty>>>>>


Avoid the 2015 PQRS penalty

If you missed the Oct. 18 administrative claims deadline for participating in the Physician Quality Reporting System (PQRS), you still have the opportunity to avoid a 1.5% 2015 PQRS penalty. If you have been submitting claims-based reports, keep going. If you have signed up for the administrative reporting option, you should be set to avoid any 2015 penalties. The only other option for reporting is the use of a registry. You will have to make sure that you are signed up and ready to submit through the registry by the end of the year, with reporting required by the end of February.

Be prepared for changes in the number of measures to be reported, reporting periods, and methods for reporting in 2014.

Sunshine Act expanded

This tidbit of information may be of value: The government, in all of its wisdom, has decided to include medical textbooks, reprints of peer-reviewed scientific clinical journal articles, and abstracts of these articles as transfers of value that are reportable under the Sunshine Act.

Potential cuts for in-office procedures

CMS proposed to use outpatient prospective payment system and ambulatory surgical center (ASC) rates to cap practice expense relative value units for office procedures in June. Practice expense RVUs are developed by a very rigorous evaluation of actual costs for physicians to provide services. CMS is essentially saying, “Throw that process out the window,” or at least ignore the actual cost for physicians to provide services in the office if the actual cost is more than in the ASC or in the outpatient hospital setting.

Hopefully, this will not be included in the final rule. The AUA and many other groups have objected to the change. Hope for the best, prepare for the worst. Stay tuned.

Prepare for ICD-10

ICD-10 will be implemented on Oct. 1, 2014. To ensure you are ready, it is time to train your champions and prepare to learn the system. Training for clinical staff and your billing and coding staff will need to begin in earnest in the spring and summer of 2014. Physician Reimbursement Systems and others will be offering training online and in person. Check the Web for available seminars and webinars.

Coming soon: Value-based payment

CMS has proposed tying a new value-based payment modifier to PQRS reporting and the total cost of care. Value-based payment will be part of your future in Medicare and in the private sector. You will need to develop data access and analysis to defend your quality, regardless of how it is defined.

Review guidelines and implement treatment protocols and measurements in your practice to adhere to quality protocols. Learn treatment costs per disease and prepare for payment changes that will affect your treatment and diagnostic choices.

SGR reform?

Replacing the sustainable growth rate (SGR) formula is being discussed, but no solution has been passed. Every year for the past 5 years, this has been a major concern. The good news is that the cost of SGR repeal is lower than it has been for some time. The bad news is that Congress has demonstrated no ability to address any issues requiring foresight and compromise.

We see that there are proposals to fix the SGR tying long-term changes to increased value-based adjustments and remain hopeful that a fix or another delay will be passed. At this point, we must recommend that you prepare for a 24% decrease in Medicare fees.


Continue to Conclusion>>>>>



The New Year will provide many challenges and changes to the practice of urology. The outlook is not rosy for the short term; however, we feel that with strong organizational and structural leadership, urology can survive the winds of change that are coming fast and furious in the health care marketplace.

Long term, urology is in a good position. Being able to adjust to the changing marketplace will be difficult, but it is possible. Demographics and the laws of economics point to better times in the future for those practices that can adapt and survive.UT

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