Urodynamics Procedures Guide to Reimbursement Based on the Medicare Program Physician Fee Schedule for 2002

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Urodynamics Procedures – Guide to Reimbursement As in all procedures, there are “reasonable and customary” fees for urodynamcis procedures which are used for billing to private insurance companies; there are fee schedules provided through managed care contracts; and there is the Medicare (HCFA) payment schedule which uses a “Resource Based Relative Value Scale” (RBRVS). Many clinics use the Medicare fee schedule amount to determine the lowest amount of reimbursement likely to be received for providing a new service. Following is a summary of information on Medicare RBRVS payment for determining reimbursement, taken from Federal Register, Vol 66, No. 212 issue “Medicare Program; Revisions to Payment Policies and Under the Physician Fee Schedule for Calendar Year 2002; Final Rule and Notice”. Geographic Practice Cost Indices were published in Vol. 66, No. 212, E (11/1/01).

Medicare Formula Payment for services under the Medicare RBRVS fee schedule is the product of three factors: 1. a nationally uniform relative value (RVU) for the service, 2. a geographic adjustment factor (GPCI) for each physician fee schedule area, and 3. a nationally uniform conversion factor (CF) for the service, which converts the relative values into payment amounts. There are three conversion factors: surgical services, primary care services and other nonsurgical services. 1. Relative Value Units (RVUs). For each procedure (CPT code), there are three relative value components: 1. an RVU for Physician work, 2. an RVU for practice expense, and 3. an RVU for malpractice expense. 2. Geographic Adjustment Factors (GPCI): For each RVU component, there is a geographic practice cost index (GPCI) for each fee schedule area. The average GPCI = 1.0. 3. Urodynamics Procedures Conversion Factor (CF). 2002 conversion factor is……..$36.1192

Medicare RBRVS Fee Schedule Formula Payment = [(RVUPhysician Work x GPCIPhysician Work)+(RVUPractice Expense x GPCIPractice Expense) + (RVUMalpractice x GPCIMalpractice)] x CF

National Allowable Average (NAA). The NAA is the average Medicare payment. NAA = Total RVUs for the specific procedure x CF (GPCI = 1.0). Medicare will reimburse 80% of this amount; the other 20% is patient co-pay (co-insurance or out-of-pocket expense).

Medicare "National Allowable Average" for Common Urodynamics Procedural Codes

CPT Code 51797 51795 51726 51772 51741 51736

Description Intraabdominal Voiding Pressure Bladder Voiding Pressure Complex Cystometrogram Urethral Pressure Profile Complex Uroflowmetry Simple Uroflowmetry

Physician Work RVUs

Practice Expense RVUs

Malpractice

Total

National Allowable

RVUs

RVUs

Average

1.60 1.53 1.71 1.61 1.14 0.61

3.55 3.69 3.51 3.48 1.46 0.86

0.14 0.18 0.15 0.16 0.09 0.05

6.61 6.55 6.51 6.50 3.16 1.73

$239 $237 $235 $235 $114 $62.62

Coding Guidelines – Multiple Procedures Modifier “-51” when two or more surgical services are performed on the samed day or at the same session. The major procedure should be reported first with the normal change (no modifier), and secondary procedures should be listed next (ranked in order of RVU value) with the -51 modifier. Note: appropriate use of modifiers is critical under government programs (such as Medicare). Private payers vary as to their expectations / requirements and capabilities to recognize modifiers, although it is good practice to use modifier “-51” in billing secondary procedures for all payers. Medicare reduction. Effective January 1, 1995, HCFA changed its rule for reimbursing multiple surgical services. If a physician performs more than one urodynamic procedure on the same patient on the same day, Medicare will pay as follows: the primary procedure (billed first) at 100% of the RBRVS fee; the second through the fifth procedures (billed using a “-51” modifier) will be paid at 50% of the RBRVS fee. Procedures after the fifth require carrier review to determine payment. Note: For Medicare reimbursement, monitor payments to make sure claims for multiple procedures were processed correctly.

CPT Coding Guidelines – Urodynamics Procedures

All procedures in the “Urodynamics” CPT code book section (51725-51797) imply that services are performed by, or are under the direct supervision of, a physician and that all instruments, equipment, fluids, gases, probes, technician’s fees, medications, gloves, trays, tubing and sterile supplies are provided by the physician.

ICD-9-CM Diagnostic Codes Diagnostic and disease reporting is required on all claims to Medicare, Medicaid and other payer groups for payment. Each service / procedure billed should be supported by an ICD-9CM diagnostic code that substantiates the need for those services provided. Common codes used for urodynamic studies include: ICD-9-CM Diagnostic Codes 596 596.5

Bladder neck obstruction Functional disorders of the bladder

596.52

Low bladder compliance

596.54

Neurogenic bladder

596.55

Detrusor sphincter dyssynergia

596.8

Other specified disorder of bladder (cystocele)

598

Urethra stricture*

600

Hyperplasia of prostate*

618

Prolapse of vaginal wall without mention of uterine prolapse (cystocele, urethrocele, female)

625.6

Stress incontinence (female)

788.30

Incontinence of urine

788.31

Urge Incontinence

788.32

Stress incontinence (male)

788.33

Mixed incontinence (female and male)

788.35

Post-void dribbling

788.36

Nocturnal enuresis

788.39

Other urinary incontinence

* use additional code to identify urinary incontinence (625.6,788.30 - 788.39)

The Federal Register is available free Online at http://www.access.gpo.gov/su_docs/regulatory.html

“Other Payer” Fee Schedules Commercial insurers reimburse urodynamics procedures and other surgical services under a payment method based on “reasonable and customary” fees. Reasonable and customary fee schedules, unlike Medicare’s RBRVS payment schedule, are based on statistical surveys of physicians’ established fees within specific geographic areas. Following are urodynamic fee ranges to help analyze charge structures. Actual fees can vary widely and should reflect a fair and competitive charge for a physician in the same town. Payment Fee Range* CPT Code

Description

Low

High

51797

Intraabdominal Voiding Pressure

$240

$290

51795

Bladder Voiding Pressure

$240

$285

51726

Complex Cystometrogram

$237

$289

51772

Urethral Pressure Profile

$239

$287

51741

Complex Uroflowmetry

$152

$183

51736

Simple Uroflowmetry

$75

$91

Note: Payer policies vary dramatically on reimbursement for multiple procedures performed on the same patient, same day. Some will pay a t 100%, others will reduce payments for secondary procedures by 25 or 50%. Others follow Medicare’s rule prior to 1995; that is, 100% on first procedure, 50% on the second and 25% on the third-fifth. Experts suggest the following if you have experienced reimbursement problems: 1) list full “reasonable and customary” fee for all procedures; 2) for secondary procedures, use modifier “-51”; and 3) write clearly on the claim that “this is your full fee”. This will disclose all the facts to claims processors to help achieve fair reimbursement.

Hospital Reimbursement for Urodynamics Procedures ICD-9-CM Procedure Codes

Hospitals use ICD-9-CM Procedure Codes in addition to ICD-9-CM Diagnostic Codes when billing inpatient or outpatient services. The following codes can be used by hospitals for billing urodynamics procedures to Medicare or other third party payers: ICD-9-CM Procedure Codes 89.22 89.24 89.25

Cystometrogram (CMG) Uroflowmetry (UFR) Urethral Pressure Profile (UPP)

Medicare Reduction Medicare reimburses hospital outpatient facilities on a reasonable cost basis which depends on the hospital specific cost-tocharge ratio. Equipment used for urodynamics studies is billed as part of the facility service. Physician services are reimbursed separately, and the CPT codes should be billed using the “-26” (professional component) modifier.

Modifier “-26”, Professional component. Modifier “-26” is used when billing CPT codes for the professional component of a procedure which normally includes both technical and professional components. Use this modifier when billing a Medicare patient in situations where the physician only interprets the results and/or operates the equipment. Modifier “26” is used when the physician does not own or provide the instrumentation, equipment, fluids, gases, etc. Typically, the professional component payment (billed with modifier “-26”) averages 75-85% of the complete procedure.