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The definition of "consult" has moved the target for reimbursement over the years.
Q I am the compliance officer for a urology group in Syracuse, NY. I recently informed our physicians that, according to my research, they couldn't bill for a consult if a patient comes in to discuss a vasectomy. One physician said it is acceptable to bill this way. Can you assist me?
If the patient was referred to the urologist specifically for a vasectomy and the urologist provides "a significant and separately identifiable E&M service," the urologist should charge the appropriate new patient or established patient code with a –25 modifier. However, if the discussion is short, the documentation is limited, and the encounter cannot be considered "significant and separately identifiable," then the vasectomy should be charged without an E&M code.
Q Can you make suggestions as to appropriate current CPT codes regarding pelvic floor therapy? The dilemma: Medicare pays for 90911 (biofeedback), but commercial payers frequently call it experimental. The physical therapy codes have to be administrated by a physical therapist for Medicare to recognize them as medically necessary, but commercial payers seem to allow the service to be provided by a nurse incident to the doctor. Is it ever appropriate for the doctor's office to have different codes based on payer? How do you see the roles of 51784 and 91122 in this scenario?
A There may be times when coding should be different for different payers; however, these instances should not vary from CPT conventions unless you have written instruction from the payer to do so. Examples of billing payers differently could include use of different modifiers for private payers for E&M codes, billing of code combinations to some carriers and not others, billing of unlisted codes instead of Category III codes, etc.
To re-emphasize, if you vary your billing from CPT-accepted rules because of recommendations by the payer, ask for the recommendations in writing.
Regarding the use of codes 91122 and 51784, in this scenario, both codes are considered to be diagnostic in nature. Typically, billing of either code at the beginning of the biofeedback therapy to establish a baseline and at the end of the therapy to determine improvement could be appropriate. However, medical necessity should be carefully considered for billing of either code throughout the treatment sessions. By definition, biofeedback requires some measurement of the muscle groups in question, with some feedback to the patient (ie, visual, audio, etc.).
When considering biofeedback versus electrical stimulation or other therapeutic codes, one must consider what service(s) and protocols are being provided. Although coverage may play a part in the decision of the provider or patient to have the service, it should not be the driving factor in coding for the service, as there are specific codes that depend on the actual service being provided.
In electrical stimulation, a sensor delivers stimulation to a muscle or muscle group to cause contraction or identification of the muscle. Biofeedback measures and displays the ability of the patient to contract and/or relax a muscle or muscle group. You will need to select the appropriate code for the services provided.
Finally, although all services in the physical medicine section (97001-97799) will be subject to the physical therapy cap, we do not see a restriction in the Medicare regulations that would prohibit the physician's office from billing physical medicine codes. There are regulations that specify when and under what conditions a physical therapist may bill for services.
Again, the diagnostic codes (ie, 51784, 91122) should not be routinely used for therapy sessions, since doing so may trigger Medicare audits.
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.