Secure contracts with nursing homes to ensure payment

Mar 01, 2006

How do I charge for a patient sent from a nursing home for a consult who, upon evaluation, required a cystoscopy?

Q How do I charge for a patient sent from a nursing home for a consult who, upon evaluation, required a cystoscopy?

If the patient is in the first 100 days of discharge from the hospital and Medicare is paying the bill through Medicare Part A to a skilled nursing facility (SNF), E&M servi-ces are paid as outpatient services in your office without a problem. However, any "procedure" will be paid as if it were perform-ed in a facility, or a "facility fee." Any service you provide with a technical component and a professional component will only be paid for the professional component. Most important, drugs normally paid by Medicare Part B will not be paid by Medicare Part B when given to SNF patients.

Q I work in an office with six physicians. We've set up an operative suite and are considering doing a photoselective vaporization of the prostate (PVP) laser procedure for BPH as an outpatient procedure in the office. We arranged for the anesthesia and all the safety equipment that is required. How do we bill for the procedure, and what will we be paid?

A I have good news to report. Last year physicians used 52647, which paid both a facility fee for a procedure performed in the hospital in addition to a non-facility fee for a procedure performed in the office or other outpatient setting. A change in the terminology on the laser codes in CPT prevented 52647 from being a correct code for reporting the PVP procedure as of Jan. 1, 2006. As of this date, therefore, 52648 is the only correct code to use.

The good news came in a recent press release from PVP device maker Laserscope, which stated:

"The correct way to code the laser as an outpatient or inpatient is to use the 52648 in place of service, and the national average payment will be approximately $3,100 for the outpatient procedure and approximately $600 for the procedure if in the hospital."

In summary, CMS finally agreed to pay the non-facility fee for the 52648 code as of the beginning of 2006. The new payment rule will apply to all laser treatments of the prostate that are described by that code.

Q There are a number of different LHRH products now available on the market (both injections and implants). In the case of a Medicare patient who has no preference between an injection and an implant, is there any financial advantage of using one drug over the other?

A The answer to your question depends on your contract for the drug. There are several issues to consider in making your decision. First, consider the spread between the cost of the drug and the payment you will receive from Medicare. Obviously, if you're using a 3-month drug, that profit will occur four times a year, whereas an implant provides a once-a-year profit.