Physician Coding and Reimbursement for Urodynamics

$\begin{array}{l}\mathrm{F}\mathrm{acility}\;\mathrm{P}\mathrm{ayment}\;\mathrm{Amount}=\\ {}\kern1.12em \left[\left(\mathrm{Work}\;\mathrm{R}\mathrm{V}\mathrm{U}\times \mathrm{Work}\;\mathrm{GCPI}\right)+\left(\mathrm{Facility}\;\mathrm{P}\mathrm{E}\;\mathrm{R}\mathrm{V}\mathrm{U}\times \mathrm{P}\mathrm{E}\;\mathrm{GCPI}\right)+\left(\mathrm{M}\mathrm{P}\;\mathrm{R}\mathrm{V}\mathrm{U}\times \mathrm{M}\mathrm{P}\;\mathrm{GCPI}\right)\right]\times \mathrm{C}\mathrm{F}\end{array}$

$\begin{array}{l}\mathrm{Non}-\mathrm{Facility}\;\mathrm{P}\mathrm{ayment}\;\mathrm{Amount}=\\ {}\kern1.12em \left[\left(\mathrm{Work}\;\mathrm{R}\mathrm{V}\mathrm{U}\times \mathrm{Work}\;\mathrm{GCPI}\right)+\left(\mathrm{Non}-\mathrm{Facility}\;\mathrm{P}\mathrm{E}\;\mathrm{R}\mathrm{V}\mathrm{U}\times \mathrm{P}\mathrm{E}\;\mathrm{GCPI}\right)+\left(\mathrm{M}\mathrm{P}\;\mathrm{R}\mathrm{V}\mathrm{U}\times \mathrm{M}\mathrm{P}\;\mathrm{GCPI}\right)\right]\times \mathrm{C}\mathrm{F}\end{array}$

There are two different practice expense (PE) RVUs for every CPT code because reimbursement depends on whether or not the physician performed the service in a free-standing outpatient clinic or a facility setting. Hospitals, hospital-based clinics, and ambulatory surgery centers (ASC) are considered “facility” settings. Hospital and hospital-based clinics are also referred to as Ambulatory Payment Classification locations (APC). The APC designation pertains to the way the hospital is reimbursed (outpatient and not inpatient reimbursement). In these facility settings, the PE RVU value for the physician reimbursement will be lower. This takes into account some of the services provided by the hospital.

The conversion factor (CF for 2013 was $34.0230) is a simple way for Medicare and the government to control cost by adjusting physician reimbursement [4]. Recently, the implementation of cuts to the conversion factor has been an important topic in the news and medical society communications. Large decreases in the CF have continually been delayed by congress over the past 5 years. Unless it is again delayed, changes to the conversion factor will cut physician reimbursement by 25 % in January 2014.

RVU Use with Diagnostic CPT Codes

For diagnostic CPT codes, the total (global) RVU is a sum of the Professional Component (PC) and Technical Component (TC) RVUs. For a diagnostic test, the PC is similar to the Work RVU and the TC is similar to the PE RVU plus the MP RVU. The global amount paid to a physician who performs a diagnostic test such as urodynamics in the non-facility setting is approximately the sum of the professional component and the technical component payments that are reimbursed for diagnostic procedures performed in a facility.

$\mathrm{Global}\;\mathrm{Payment}\;\mathrm{Amount}\approx \mathrm{P}\mathrm{C}\;\mathrm{Payment}\;\mathrm{Amount}+\mathrm{T}\mathrm{C}\;\mathrm{Payment}\;\mathrm{Amount}$

In the facility setting, the professional component reimburses for the interpretation of a test results and the TC reimburses for the cost of equipment, the technician, and the malpractice expense covered by the hospital.

If a diagnostic test is performed in a facility then only the PC will be used to calculate reimbursement to the physician. However, if a diagnostic test is not being performed in a facility then the physician is reimbursed based on the total Global RVU. It is the authors’ opinion that if a physician is performing diagnostic tests in a facility setting, the facility should be paying a portion of the physician’s malpractice expenses because the facility is being reimbursed for malpractice coverage by CMS as part of the TC. Of note, there are some CPT codes that are either only PC or only TC. Lastly, the TC payment amount reimbursed to a facility also depends on whether it is a hospital or ambulatory surgery center.

International Classification of Diseases-9th Revision-Clinical Modification Codes

ICD-9-CM Codes are unique numbers assigned to a disease process or diagnosis. They are used as a way for payers to verify that the CPT codes listed are medically necessary. Each CPT code billed should be supported by an ICD-9-CM diagnosis code that substantiates the need for those services provided. In addition, because they also imply the severity of a patient’s medical problem, ICD-9-CM codes also limit which CPT codes can be used. Commonly accepted ICD-9-CM codes for urodynamics are listed in Table 4.1.

Table 4.1

Appropriate diagnosis ICD-9-CM codes for urodynamics (adapted from Ingenix [5])

ICD-9-CM code with corresponding description
344.61	Cauda equina syndrome with neurogenic bladder	598.1	Traumatic urethral stricture
595.1	Chronic interstitial cystitis	598.2	Post-operative urethral stricture
595.2	Other chronic cystitis	600.01	BPH with urinary obstruction and LUTS
595.82	Irradiation cystitis	618.01	Cystocele, midline
596.0	Bladder neck obstruction	618.02	Cystocele, lateral
596.1	Intestino-vesical fistula	625.6	Female stress urinary incontinence
596.2	Vesical fistula	753.6	Congenital atresia/stenosis of urethra/bladder neck
596.3	Bladder diverticulum	788.21	Incomplete bladder emptying
596.4	Bladder atony	788.31	Urgency incontinence
596.51	Bladder hypertonicity	788.32	Male stress incontinence
596.52	Low bladder compliance	788.33	Mixed incontinence (urge and stress) male and female
596.53	Bladder paralysis	788.37	Continuous leakage
596.54	Neurogenic bladder not otherwise specified	788.41	Urinary frequency

Proper coding of clinical procedures and diagnoses is dependent on the material documented in the patient’s medical record. CMS determines which ICD-9-CM codes are required for a CPT code to be covered or reimbursed. However, because each state has a particular carrier for government Medicare, the required ICD-9-CM codes vary from state to state.

Modifiers

Modifiers are two digit codes that are added to a CPT Procedure code or E&M code in order to clarify the services being billed. The four most commonly used modifiers for urodynamic billing by a physician are the -26, -51, -25, and -59 modifiers. This information is summarized in Table 4.2.

Table 4.2

Summary of commonly used modifiers (adapted from: current procedural coding expert by Optum 2012) [6]

Modifier 26	Professional component only of a procedure or service
Modifier 51	Multiple procedures performed at same session by same provider
Modifier 25	Significant, separately identifiable evaluation, and management service by same physician or other qualified health care professional on the same day of procedure or other service
Modifier 59	Distinct procedure, used to identify a procedure not usually reported together but are appropriate under the circumstances
Modifier 58	Staged or related procedure or service by same physician or other qualified health care professional during post-operative period
Modifier 78	Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the post-operative period
Modifier 79	Unrelated procedure or service by the same physician during the post-operative period

The -26 modifier is used ONLY for diagnostic tests performed in a facility setting where reimbursement is being shared between the facility and the physicians. The -26 modifier designates the professional component of a service provided, such as interpretation of a test results. The -26 modifier tells CMS or other payers that it needs to split reimbursement between the physician and the facility. The physician will receive reimbursement for the Professional Component and the facility receives reimbursement for the Technical Component.

The -51 modifier is used to designate that multiple related procedures were performed on the same patient at the same visit. The first CPT code has the highest RVU value, will not have the modifier appended, and will be reimbursed at 100 % of the allowable reimbursement. All additional codes will have the -51 modifier appended and be reimbursed at 50 % of the allowable reimbursement.

The -25 modifier is used when billing for both an E&M code and a procedure code on the same day. This is often used if the urodynamics are done in the setting of a new patient encounter. The E&M code should be separate, identifiable, and above and beyond what is expected for the procedure/s performed. As long as the visit is properly documented and the modifier is used, billing for a new patient encounter and urodynamics on the same day should not affect reimbursement.

The -59 modifier is used to designate a procedure that is distinct or independent from other services performed on the same day. In the case of urodynamics, this is commonly appended to the cystoscopy CPT code (52000) if a cystoscopy was performed on the same day as urodynamics. The use of this code also does not affect reimbursement.

Three other modifiers that might be used with urodynamic coding are -58, -78, and -79. These modifiers are necessary if the urodynamic test is performed while patient is in a 90-day post-surgery global period. The -58 modifier is used if the urodynamic test is a planned or staged part of the surgery (dictated as part of the plan in the operative note) that created the post-operative global period. The -78 modifier is used when there is an unplanned need for urodynamics during the global post-operative time period because of a medical problem related to the original surgery. The -79 modifier is used when the same physician is performing urodynamics on a patient during the post-operative global time period for a medical condition not related to the original surgery. Of note, when the above three codes are used correctly, reimbursement should not be affected.