If you’re looking for sources of reimbursement for urology visits that you haven’t billed in the past, you’re in luck. Uncover the overlooked services that can lead to increased, deserved reimbursement for your urology practice.
Mistake: Urologists often fail to bill for or correctly code many types of E&M services, which can lead to lost revenue and claims denials, according to urology coding guru Michael Ferragamo, who will present four sessions on urology coding in the upcoming 2019 Coding Updates Virtual Boot. Ferragamo will also address common misuse of urology modifiers—and explain how to properly use modifier 25 with E&M services in urology to keep denials at bay.
Step 1: Follow the ‘Incident To’ Rules
Step one to taking full advantage of hidden opportunities for increased reimbursement is to nail down your understanding of “incident to.”
Definition: “Incident to” refers to services or supplies furnished incident to a physician’s professional services as an integral part of those services and in the course of diagnosing or treating an injury or illness, according to Noridian Healthcare Solutions. Such services must be performed in the physician’s office or in the patient’s home and must be part of the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the ongoing treatment course.
As a general rule, you can bill incident-to services only for the office setting, according to Palmetto GBA. And to meet the incident-to requirements, the supervising provider must be present in the office or office suite to render assistance if necessary. You cannot bill incident-to if the hospital is billing and the physician is a hospital employee.
Caveats: If the urologist establishes an office in a larger outpatient setting, you can bill incident-to services in certain circumstances—as long as the incident-to services and requirements are confined to the specific part of the facility designated as the urologist’s office. A group of physicians, who are not hospital employees, can bill incident-to services if the physicians are incurring the expense.
Incident-to services can be performed by non-physician practitioners (NPPs) such as nurses, technicians, and therapists. Medicare also pays for services rendered by employees of Clinical Psychologists, Nurse Practitioners, Certified Nurse Midwives, and Clinical Nurse Specialists.
Decode Split/Shared Billing
Another good source of revenue is the split/shared E&M visit.
Definition: A split/shared E&M visit is a “medically necessary encounter with a patient where the physician and a qualified non-physician practitioner (NPP) each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service,” according to First Coast Service Options, Inc.
Requirements: To meet the split/shared billing requirements, a substantive portion of the E&M visit must involve all or some portion of the history, exam, or medical decision-making key components of an E&M service. Also, the physician and NPP must both belong to the same group practice or employer.
Like incident-to services, split/shared billing comes from the physician. But there are key differences between incident-to and split/shared billing: the place of service, applicable visit types, level of physician involvement, and more, according to a presentation for the Healthcare Financial Management Association’s Massachusetts-Rhode Island Chapter.
Unlike incident-to services, which typically occur in the office setting, split/shared services may occur during initial hospital care (99221-99223), subsequent hospital care (99231-99233), discharge management (99238-99239), observation care (99217-99220, 99234-99236), emergency department visits (99281-99285), and hospital provider-based office visits (99201-99215).
Exclusions: But split/shared visits cannot include consults, procedures, critical care services, skilled nursing or nursing facility services, or resident/teaching physician services.
Bill for All Services Rendered
Example: In your urology office, the NPP performs a portion of an E&M encounter, and the urologist completes the E&M service, First Coast illustrated. If the incident-to requirements are met, you would report the services under the physician’s National Provider Identifier (NPI). But if the incident-to requirements are not met, you would report the services under the NPP.
Bottom line: Keep in mind that you can indeed code and bill for many types of special E&M services in urology, Ferragamo stresses. In his presentation, he details what codes to use for often-overlooked but fully payable services, including consultations, emergency room visits, critical care, and observation services. Plus, he’ll clue you in to how to properly use tricky urology modifiers.
