Is it time to dump a payer? Many factors to consider

January 1, 2007

Control of postoperative pain is usually considered follow-up care similar to wound care, removal of sutures, and other related services.

Q. We own our urodynamics machine and perform urodynamics in our office. We bill for the technical component the day the patient comes into the office for the procedure under the supervising urologist who is in the office that day. We then bill for the professional component the day the patient's urologist does the interpretation. These two components are always done on different dates.

We bill the following codes: 51726, 51741, 51797, 51784, and 51795 with the TC modifier with the date the urodynamics was done under the supervising urologist, and then bill the same codes with the –26 modifier under the urologist who does the interpretation, providing the date he does that.

The problem is that our number-two payer states we should bill it globally under just one physician and it would fall under the "surgery" multiple procedure code. Medicare in our state (Ohio) pays us correctly, as do all other private insurance companies. The payer that does not subsequently pays much less than everyone else, including Medicare, and for this reason we plan to opt out of our contract with them. Is this what you would advise, or should we try to work out an agreement with them?

We assume by your question that you are billing correctly for these services. (You have urodynamics testing provided on days when the interpreting physician is not in the office, and you do not split billing of the service if both providers are in the office when the service is provided.) The underlying problem you face actually stems from the fact that these codes are radiologic services and not surgical services, but are numbered in the surgery section. As such, the different way that each payer treats multiple procedure reductions and "incident to" services will affect your payment.

As you know, Medicare multiple procedure reduction rules do not require the reduction of the TC of these urodynamics services, but do require the reduction of the global component and the professional component. In essence, the service is treated like a surgery if billed with no modifier or billed with the –26, and is treated like a radiologic service when it is billed with the –TC. The private payer has the ability to treat these services and the incident to rules, which require separate reporting for Medicare, differently than Medicare does. Therefore, unless you can negotiate a change, you truly are stuck with a decision to walk away, accept the lesser payment, or modify the services you offer to that group of beneficiaries.

Q. I am new to urology coding and wondered if you could bill for a penile block when performing a meatotomy. I am also unsure about which nerve the penile block falls under. The urologist gave the penile block for postoperative pain control. 64430 is used for a pudendal block, and 64450 is for a peripheral nerve and I thought the latter would be correct. When I run codes 53020 and 64450 through the CCI edits, a modifier –59 can be appended to 64450 to bypass the edit, but I was unsure if this was appropriate to control post-op pain. Please give your opinion as to which code should be used and whether modifier –59 would be appropriate.

A. Control of postoperative pain is usually considered follow-up care similar to wound care, removal of sutures, and other related services. However, many offices are billing and being paid for pain control services under the auspices of care above and beyond what is normal.

Although you may be successful in payment for these services, the cost and effort for provision of these services is minimal and should be included.

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.

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.