Physician Reimbursement Systems

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

Procedural CodingUrologists Role 3

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

Bundling Rules

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

Physician Reimbursement Systems