Billing and Coding Pitfalls for Urology Practice Managers

At the American Urological Asso­ci­ation annual practice management meeting, M. Ray Painter, MD, a practicing urologist with a strong interest in medical economic issues, and Rick Rutherford, MPE, CHA, Director of Practice Management for the American Urology Association, outlined what urology practice managers need to know to prevent succumbing to billing and coding pitfalls. They offered guidance based on Medicare standards for “incident to” services, “shared” services, office supervision requirements, time measurements for evaluation and management (E/M) coding, and red flags for auditing.

“Incident to” Services

If, after being seen by the physician who has developed a plan of care for the patient, a patient presents with a problem, the nurse practitioner (NP) or physician assistant (PA) can see the patient under the plan of care. If the treating physician is out of the office when services are provided to the patient, the care can be listed as “incident to.”

Medicare Shared Services and Office Supervision Requirements

For Medicare services that are not related to “incident to,” the physician must be in the office and face-to-face with the patient and involved in all or part of history taking, examination, or the medical decision. If a physician orders a procedure, but the physician on duty does the procedure, the physician on duty gets paid for the procedure. If the physician who performed the initial service has been actively involved in the patient’s treatment and provided supervision to the NP or PA, Medicare will pay 100% of the fee on the physician’s fee schedule. If the NP or PA provides the E/M service to a new patient or without direct personal supervision from the physician, Medicare will pay only 85% of the fee listed on the fee schedule.

Dr Painter and Mr Rutherford also outlined the hottest auditing issues:

• Modifier 25 (“Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.”): Commercial payers are profiling providers to scare physicians into accepting net pay for services. If you receive a profiling report, be wary of it.
• Electronic health record (EHR) document cloning: Long-term follow-up care is especially vulnerable. Be sure to document fresh review of history and systems, including vital signs, height, weight, blood pressure, and history of present illness. Be sure to avoid making it look as though you are cutting and pasting from previous visits.
• Cloning: As of April 2013, there is a 2% Medicare sequester budget fee. You will be able to write off the 2% loss.
• PQRS #48, assessment of urinary incontinence (UIC) in a medical female older than age 65 years: Many urologists select the measure and file it. No diagnosis is required. Even if a patient does not have UIC, you must write “Yes.”
• PQRS #24 EHR has been retired.