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This resource provides essential insights into the procedural coding and reimbursement practices specifically for urologists. It outlines fundamental responsibilities including documentation, service identification, and understanding global and bundling rules. The guide emphasizes the importance of modifiers, communicating effectively with billing departments, and making informed decisions on whether to charge for certain procedures. By adhering to these guidelines, urologists can ensure accurate coding, expedite reimbursement, and enhance overall operational efficiency.
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Physician Reimbursement Systems The Premier Source for Coding & Reimbursement Assistance 2635 Walnut St. Denver, CO 80205 800.972.9298 Fax 303.534.0577 www.prsnetwork.com 1
Urologists Role • Must do four things • Identify all services • Document all services • Determine “circumstances” • Communicate • Consider two sets of rules • Bundling - multiple procedures • Global - previous procedure 3
Multiple procedures • Component or separate • Should you bill for all • ? Modifier
Bundled Codes • Procedures that are an integral part or component of another procedure
Multiple Procedure Billing • Is one procedure an integral part or component of the primary Procedure? • If answer is - “YES” • Do Not Charge • Do Not Mark on Communication Form
Multiple Procedure Billing • Is one an integral part or component of another? • If answer is “NO”- Charge!!! • Mark on Communicate Form • Add modifier to lesser procedure(s) Note: do not add modifier to primary procedure
Modifier – 59* • Different patient encounter • Different site or organ system • Separate incision or excision • Different procedure • Procedures only • Same day, only *Note-use, -RT & -LT, if appropriate 35
GLOBAL • I Patient has had recent a procedure 10
GLOBAL PRE-OP PROCEDURE POST-OP RELATED + All SERVICES UNRELATED TO THE PROCEDURE & SOME COMPLICATIONS
Medicare Global - Examples • 0 Day • All endoscopy • except Prostate • 10 Day – Day of + 10 • Circ • Vas • -90 Day: Day before, Day of, + 90 • most major open procedures • ESWL 39 39
Modifier -58 Staged or Related Procedure or Service • (a) planned or anticipated (staged); • (b) more extensive than the original procedure • (c) for therapy following a surgical procedure.
Modifier – 79 • Unrelated procedure or service by the same physician during the postoperative period • Use New Diagnosis
Modifier – 78 • Related Procedure / Complication • Formal - OR • Procedure Rm • Pays Work Value Only
CommunicateStep #1 • Mark all services to be charged on communication form • Communication form • Customized to include all hospital procedures • Coding pre-determined by coding staff & Urologists to be accurate • ? Modifier
CommunicateStep #2 • Add Modifiers • Multiple procedures • No modifier on primary procedure • Add modifier to all lesser procedures to be billed -59 • Or, Rt & LT • Within global • Identify unrelated - -79 • Staged - -58
CommunicateStep # 3 • Send to billing department to complete the process • Your job is complete • You have: • Provided adequate information for billing • Excellent documentation for appeals as needed • Avoided countless questions • Set the stage for earlier payment • Saved significant staff time
