Physician Reimbursement Systems

1. Physician Reimbursement Systems The Premier Source for Coding & Reimbursement Assistance 2635 Walnut St. Denver, CO 80205 800.972.9298 Fax 303.534.0577 www.prscoding.com 1

2. Processes • Coding and Billing department • Check modifiers and codes • Apply payer specific billing rules • Submit claim • Verify acceptance • Check status as needed • Verify payment = contract • Appeal, appeal, appeal 17 17

3. Hierarchy of rules • CPT -- is the foundation for all coding • Payer rules -- are the final rules • All other consultants, organizations, newsletters and other publications provide ideas and assist with interpretations only, no authority • AUA, no authority, but has significant influence, • Verify all recommendations 21 21

4. Procedural Rules • Specificity • Global • Bundling 3

5. Specificity • If a single code describes the procedure or procedures • must use • Do not report two codes if one code describes both procedures, even if two surgeons • Types of codes • CPT • Other HCPC codes – Medicare • Tracking - CPT Cat III Codes 38

6. Specificity (continued) • There is no code that accurately and completely describes the procedure. • CPT rules-- use unlisted • Medicare rules • Code description close, same family, same modality -- Use -52, or -22 • Unlisted 38

7. GLOBAL • I 7

8. GLOBAL - Medicare UNRELATED SERVICES UNRELATED SERVICES PRE-OP PROCEDURE POST-OP RELATED + BUNDLED COMPLICATIONS COMPLICATIONS Requiring Return to OR ADDITIONAL PROCEDURES 38

9. MEDICARE GLOBAL 0,10, & 90 DAYS 39 39

10. Global Days - AUACodingToday.com CPT 52353    CPT Description • Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)  Status: A more • Global: 000 more 7 42

11. Private Payer Not Required to follow Medicare or CPT Rules or Guidelines, • May use Global Periods Greater than Medicare for • Pre-op • Post-op • May or may not recognize modifiers 7 42

12. Key Global Modifiersfor Procedural – 58 (Staged) – 78 (Complications) – 79 (Unrelated)

13. Modifier – 78 • Related Procedure / Complication • Formal OR or • Procedure Rm • Pays Work Value Only

14. 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.

15. Modifier – 79 • Unrelated procedure or service by the same physician during the postoperative period • Unrelated to primary procedure • Use New Diagnosis 7 42

16. Bundling Rules

17. Bundling Rules • Procedures that are an integral part or component of another procedure are “Bundled” • Bundling edits are intended to prevent additional Payments for “Bundled” procedures 30

18. Bundling Rules • Apply to Billing for Multiple procedures At the same Encounter, only • Problem • Claims are paid by a computer • Computers do not recognize encounters, only calendar day’s • Not all edits are accurate. 30

19. Bundling Rules • Medicare • CCI • Denials can be appealed • Private Bundling edits • are not the same as CCI in high % of edits • 80% use versions of McKesson • most edits unknown 31

20. Bundled Codes • Procedures that are an integral part or component of another procedure • Payment edits • Medicare -correct coding edits (CCI) • For private carriers - ??

22. AUACodingToday • Free online coding tool for all AUA members 33

23. Modifier – 59 • Different patient encounter • Different site or organ system • Separate incision or excision • “Different” procedure • Procedures only • Same day, only 35

24. Modifier • – RT (Right) • – LT (Left) *Use, if applies

25. Modifier -51Multiple Procedures • Append to lesser Procedures • Use for Private ayers only • WILL NOT “UNBUNDLE” 7 42

26. Other “Same Day” Procedural Modifiers 7 42

27. Modifier – 62 Co-surgeons • Use only if 2 surgeons each perform distinct parts of a procedure or procedures described by 1 CPT code • Both surgeons must dictate an operative note for the procedure or part they performed. 36

28. MODIFIER 22Increased Procedural Service: • Use only when there is increased work, time and complexity of procedure by physician or other qualified provider • Submit Electronically 42

29. Modifiers – Split Surgical Care -54 Surgical Care Only -55 Postoperative Management Only -56 Preoperative Management Only • Requires coordination between facilities • Medicare pays each doctor according to care provided • Cannot exceed total allowed amount for one physician

30. Modifier 52Reduced services • Service or procedure is partially reduced • Procedure was started but not completed • Means of reporting without disturbing basic CPT descriptor 7 42

31. Modifier 53Discontinued Procedure • Procedure terminate due due to circumstances that threaten the well-being of the patient. • Terminated after a procedure started • Can be used with surgery of DX procedure • Do not use in ASC 7 42

32. Modifier -73Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) • .Procedure Prior to Anesthesia • Due circumstances that threaten the well being of the patient • Surgical or diagnostic procedure • Subsequent to surgical preparation ,sedation ,etc. • Reported procedure - 73.

33. Modifier -74Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia

34. .Modifier -26 Professional Component ============================= Modifier –TC Technical Component

35. Modifier -76Repeat Procedure or Service by Same Physician=========================Modifier -77Repeat Procedure or Service by another Physician