Established patient return visits: How to avoid a denial

Correction: An earlier version of this article listed incorrect CPT code numbers for the UroLift procedure. Corrections have been made and can be seen below. The correct codes that should have been referenced throughout the article are:
52441 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant
52442 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure)
C9739, 1-3 implants
C9740, 4 or more implants.
We apologize for the errors made in the article.

My doctors use an EMR with specific templates for established patient return visits. We recheck the history information on every visit and they only click the physical exam points that they performed that day. However, the review of systems; past, family, and social history; and physical exam look very similar for each patient and each visit. The history of present illness is always different, as is the plan of treatment. An outside consultant that we hired to do some audits denied the E&M visits, stating they were “cloned.” Is she correct? Can Medicare deny an entire claim or not count parts of the documentation-resulting in downcoding the service-because parts of it look similar?

You are not alone with this problem. We have run into this issue in reviewing audits performed by other consultants and compliance officers. The fact that “The HPI is always different, as is the plan of treatment” solidifies the fact that the encounter is not cloned. However, if the ROS, PFSH, and PE are identical, then you may have to prove that that information was recaptured, not copied.

We strongly recommend that you record a unique HPI and develop a new template to “update” the ROS and PFSH, as recommended by the documentation guidelines. For the PE, we would strongly encourage you to only document those exam points that are clinically medically necessary for that visit. This will reduce the likelihood a reviewer would determine that your records have been cloned.

Our practice is providing UroLift as an option to treat BPH. Most of the claims are being paid, but we often have problems getting payment for all the implants that are being used. We are using code 52441 for the first implant and 52442 for each additional implant. Often with private payers, we are only being paid for one additional implant. Medicare will typically pay for six total implants. What should I be doing?

We will split this answer into billing for the physician services and billing for the facility fees. For physician services and for those patients provided the UroLift implant in the office, the codes you have listed above are correct for the reporting of the UroLift and you have correctly noted that you are to report additional implants under code 52442.

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Although many payers have edits that will cap the total number of implants, most payers we have seen will allow up to six total implants without requiring additional documentation or changes in coding. You will need to check with each payer to determine what limits have been put in place for the number of implants and for coverage of the procedure.

The most common problem we have noted, if the service is covered by the payer, is actually a mistake in prior authorization (PA). Make sure that when you obtain prior authorization, you include the number of additional implants that will be used and reported under code 52442. As an example, if you are projecting that you are going to place four total implants, obtain a PA for 52441 x1 and 52442 x3; if you then place more implants, you have then exceeded the PA and will likely receive a denial. In short, make sure that you have a PA that covers the number of implants that you use.  Medicare does not require a PA. 

Billing for the facility will require that you have the correct reporting of the physician services but may require separate codes. Medicare has developed special interim codes-C9739 for one to three implants and C9740 for four or more implants-for the ambulatory surgery center and hospital. Hospitals are also required to submit the actual number of implants under code L8699. Payment will not change but will be tracked for potential coding adjustments at a later date.

For private payers, you will need to check with each payer for special reporting requirements. As a reminder, payers will match facility and physician coding, prior authorization for the number of implants, and proper reporting of physician services for all implants is required for proper payment to the facility.

Next: Coding for the Rezum system

We have been using the Rezum system to treat some BPH patients. Based on information provided by the manufacturer, we have been using code 53852 to report the service and get paid. Our Medicare carrier published an article requiring that we now report Rezum under code 53899. Do we need to change the way we code Rezum for all our payers?

The short answer is no. The AUA has independently and very carefully reviewed the Rezum procedure and has recommended code 53852 to report the service (bit.ly/prostatecoding). The AUA is very careful in its review process of all new technology using a process that takes into consideration all aspects of the new technology and the services associated with delivering care with the technology. The AUA Coding and Reimbursement Committee requires careful disclosure of all members of the committee to avoid bias in an effort to provide a fair determination based on clinical evidence. Although the AUA is not a payer and cannot make rules for payment, the AUA is a very respected voice for the practicing urologist and is looked to by industry and the American Medical Association to assist in interpreting urology coding issues. Therefore, we recommend that you continue to report the Rezum under code 53852 unless instructed otherwise by the payer.

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For Medicare carriers and other payers that instruct you to use the unlisted code 53899 to report the procedure, make certain that you are reporting correctly. Correct reporting for an unlisted service code requires that you include in Box 19 an adequate description of the procedure performed and submit supporting documentation for the service, including operative/procedure notes as an attachment to the claim. Often, payers have time restrictions surrounding the submission of supporting material, so you need to make sure that you meet these requirements. It is not uncommon for payers to develop payment policies and edits that allow for payment of an unlisted procedure code without a full medical review, resulting in reasonable payment time frames. Watch coverage policies, bulletins, Local Coverage Determinations, and Local Coverage Articles for special instructions and coverage notifications for special instructions and/or coverage.

Similar to other procedures for many private payers, you will need to obtain appropriate prior authorization and check coverage for the procedure prior to reporting the service.

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Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at UT@advanstar.com. Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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