Will new urodynamics codes work for private payers?

May 1, 2010

Although the request to revise the urodynamics codes was initiated by Medicare, the request was to change the CPT code descriptions to reflect the fact that the old 51772 and the old 51795 were billed in conjunction with code 51726 almost all the time.

The AMA and AUA complied, developing three new codes:

In answer to your second question, the CPT nomenclature for 51772 is included in the new codes 51727 and 51729. The language "any technique" still includes the use of a Valsalva leak point pressure test for the urethral pressure profile study. Letters of support for urodynamics can still be found on AUA's Web site, http://www.auanet.org/.

Q We have four physician assistants (PAs) in our practice. We have asked our PAs to see patients in the hospital both as initial consults and for rounds after surgery. Can you please clarify billing for PAs in these settings both with and without services provided on the same day by our physicians strictly in the hospital?

A Your question represents a move by many urologists that makes sense from a business perspective. PAs and nurse practitioners fall under non-physician provider (NPP) payment guidelines. NPPs who have their own provider number can provide services in both the office and hospital without direct physician oversight, but are paid 85% of the physician-allowed amount if reporting services they provide under their own national provider identifier.

As hospital visits require time away from the office and potential patient revenue at full reimbursement, the services provided at a lower NPP reimbursement in the hospital represent a revenue-positive move. Additionally, hospital visits provided in the global period are not separately payable and, as such, are truly revenue losses. If patients can be seen at the same time, use of lower-cost personnel is again revenue positive to the practice.

In the office setting, the services of an NPP can be considered "incident to" a physician and billed under the physician's NPI if the physician is in the office and immediately available when the service is provided. Hospital services cannot be billed under "incident to" guidelines. However, Medicare will pay for "split or shared" visits in a hospital setting under either the physician NPI or the NPP NPI.

A visit qualifies for a split or shared visit if there is clear documentation that the physician provided face-to-face services on the same day that the NPP did. Clear documentation should include a separate note describing the services the physician provided during the visit-not a simple notation that the physician agrees with the assessment of the NPP, as this does not indicate the physician saw the patient.

Under these circumstances, the service should be reported under the physician billing number. An NPP in the same group will be subject to global rules and should not attempt to bill for visits for related services within the global period.

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.