'Incident to' service charges unchanged - for now


I read that CMS changed the rules for 'incident to' services. Is this correct, and, if so, what changes have ccurred?

Q: I read that CMS changed the rules for "incident to" services. Is this correct and, if so, what changes have occurred?

Recently, Medicare sent out a transmittal indicating that there was a change in the documentation requirements for "incident to" services, for which the individual performing the services would have to document that the qualified provider was in the office at the time that service was provided, plus some additional documentation requirements.

Currently, three conditions must be met before you can bill "incident to" services:

With those criteria met, services can be charged even if the physician did not see the patient. (Remember, there is a specific set of rules that indicate that a non-qualified provider cannot charge for an evaluation and management service other than for a first-level, established patient.)

Q: I've recently heard that there is a problem with coding for use of the Urgent PC, a device that stimulates the bladder using a needle in the tibia nerve near the ankle. We have been billing using 64555, and have been getting paid. Should we continue to bill using this code?

The AUA Coding and Reimbursement Committee recently addressed this issue and recommended that the appropriate code would be the unlisted nervous system code 64999. Some payers will continue to recognize 64555 as the most appropriate code for the procedure, although the AUA has recommended otherwise. Check with your payer for the appropriate way to report this service.

When using the 64999 unlisted code, charge what you consider to be the appropriate fee for services provided. The fee would have to be negotiated with the payer, since there is no fee attached to an unlisted code.

Documentation of the service and the medical necessity and justification also may be required. AUA is considering what steps should be taken next to resolve this problem.

Q: Please advise how to code a complex repair for subsymphyseal epispadias. A Mitchell epispadias repair was performed. This involves complete disassembly into separate corpora and urethral plate. Corpora are then attached to each other dorsal to the tubularized urethral plate. The patient also required a dorsal Stratisis graft to the corpora to correct dorsal chordee in spite of medial rotation of the corpora as part of the Mitchell operation, plus a buccal mucosa graft to lengthen the urethra. This was a very complex 6-hour operation, and CPT code 54385 does not appear to cover the procedure.

A: We agree that the value for the work performed does not appear to be adequate. Unfortunately, as you have noted, there is no code available that better describes the service provided. Under circumstances such as this, you have only a few choices, all of which will require you to submit medical records and potentially appeal. The two choices that seem most appropriate would be to bill the 54385–22 plus code 15420 for the graft or to bill 55899, unlisted male genital.

By looking at similar codes, such as 54328, 54308, or 54332 for hypospadias, you might be able to help the payer determine appropriate reimbursement for the services provided. The unlisted code would be the better choice, and should be submitted with the operative note and a cover letter discussing the similarity of the service provided to all the codes for hypospadias repair and grafting that are identified as appropriate.

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.


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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