Certain private payers are denying codes for prostate and renal biopsy, and strong documentation will be required to ensure you get paid for your services.
We are getting denials from several insurers for our Artemis prostate biopsy procedure code 76377, stating incidental, or usual, and customary. BlueCross BlueShield has a policy exclusion on this code stating that the procedure is simply a physician’s aide, like the use of a robot, and will not pay for it. Aetna does not have an exclusion policy per se; they send different denials for most radiology codes.
Before we get to a discussion of the coding for this service, we will discuss the denial types you have listed above. In effect, BCBS is stating that payment for the 3-D rendering is essentially bundled into the payment for other services rendered. Aetna’s denials are different and focus more on scope of practice. Both are difficult issues to argue as an individual physician. The bundling issue will require group intervention to demonstrate both the medical efficacy above and beyond that of a standard 2-D biopsy and a work comparison between both service types.
In short, this is an argument based on value. Peer-reviewed articles demonstrating efficacy will be required to open this door.
In addition, the effort/cost argument will have to be addressed to clearly show the service is above and beyond that of the 2-D service requirement to an extent that payment is warranted. Aetna’s denials seem to represent a turf battle over and above the value that the BCBS argument encompasses. In other words, the coding issues may not be your problem; the problem may be benefit, medical necessity, efficacy, and/or scope of practice.
From a coding perspective, the code that is charged at the time 3-D rendering is developed is 76377 (3-D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post processing under concurrent supervision; requiring image post processing on an independent workstation). It is our understanding that this service is most commonly provided by the radiologist. The AUA Health Policy Brief from Nov. 5, 2013 indicated that this code was more often reported by the radiologist performing the MRI, who then delivers the 3-D computer image to the urologist for fusion with an ultrasound. You will have to determine who did what in your case to determine whether a fight is supported by service provision.
Currently, there is no code for the fusion of the 3-D image with the ultrasound performed by the urologist at the time of the procedure. Some have tried unlisted ultrasound codes 76999 or, as the AUA recommends, 76498 unlisted MRI procedure to bill the fusion service. Both of these unlisted codes also pose coverage and benefit issues. Therefore, for easy payment and in most cases, use the usual three codes for a prostatic needle biopsy: 76872 if you perform and document a diagnostic ultrasound, 55700 for the biopsy, and 76942 for the ultrasound guidance of the biopsy.
One of our physicians does renal biopsies in the office: 76775-26, 76942-26, and 50200. Aetna pays for the second and third codes but always denies 76775. Medicare pays for all of them. What do you suggest?
76775 (Ultrasound, retroperitoneal [eg, renal, aorta, nodes], real time with image documentation; limited) is not a “gimme.” As we have counseled in the past with other diagnostic ultrasounds, it should not be charged unless you have performed the service for a documented medically necessary reason and separately documented the performance and findings supporting a limited retroperitoneal ultrasound. We assume that you have this well documented but must take this time to remind everyone of the proper path to reimbursement.
However, as you know, private payers do not always pay for what they should. As Aetna has been notorious for not paying the diagnostic ultrasound for the prostate, we are not surprised the company has chosen to deny the diagnostic ultrasound for the kidney. We recommend that you appeal with your strong documentation. If Aetna continues to behave unfairly, you may accept the bad behavior, dump the contract with Aetna, or attempt to obtain a diagnostic renal ultrasound from another source or on a different day. Official channels and civilized politics have not been successful with this bunch.
We are having a debate as to which would be the correct code to use for a Medicare patient who is being catheterized for residual urine. Would you use 51701, which specifically states for residual urine, or P9612? Also, what type of documentation would you expect to see for 51701? We feel that just stating “in/out procedure” is not specific enough documentation. We would like to suggest documenting “residual urine check, the catheter is inserted, the bladder drained, and the catheter removed.”
Code 51701 (insertion of non-indwelling bladder catheter [eg, straight catheterization for residual urine]) would be the correct code to use. P9612 (catheterization for collection of specimen, single patient, all places of service) would only be used if the catheter is for the collection of a urine specimen in a Medicare patient, not for removal or measure of residual urine.
If the primary purpose for the cath urine is to check the residual, use 51701 even if you then use the specimen to check the urine.
In the documentation of the plan of action, the urologist (physician assistant/nurse practitioner) should state, ”I’m going to obtain a residual urine because _______” or simply order the residual urine and state the reason. The procedure can be documented by the staff as follows: “A red rubber catheter was inserted, the residual urine of X cc obtained, and the cath was removed.”
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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