Urodynamic Procedure Reimbursements 2016-2018

Posted by Clark Love on May 29, 2018 7:29:29 PM

medical-billing-and-codingUrodynamic procedures can be scheduled for reimbursements through Medicare and other insurance companies. You will need to know the exact codes listed below in the article to help build a proper case for calculating how much you can be reimbursed for. The following information is a guide to help you estimate your reimbursement. However, not all reimbursements will be accepted. Contact your insurers for an assessment to check if you qualify for urodynamic procedure reimbursements. Each insurance office has strict policies and guidelines on whether you will get accepted or denied your reimbursement.

Physician Reimbursement for Urodynamic Procedures

Services that are provided by physicians are created by CPT codes which depend upon fee schedules. For Medicare, CPT codes will be assigned via Relative Value Units (RVUs). These codes are used to represent physician work, expertise, and resources for the medical service. Depending on where you receive the service or if you’re using a facility or non-facility, the expenses will change.

If more than one urodynamic procedure is done on the same day, Medicare will pay for the primary procedure with 100% coverage of the fee schedule amount, the subsequent procedure for 50% coverage of the fee schedule amount. The following CPT codes and reimbursement fees are estimated for reimbursements made in 2016-2018.

CPT Code

Description

Physician Office Setting for Non-Facility

Hospital Setting for Facility

51725

Simple Cystometrogram (CMG)

$190-193

$79

51726

Complex Cystometrogram

$266-273

$88

51727

Complex Cystometrogram w/ urethral pressure profile studies

$316-321

$110-111

51728

Complex cystometrogram w/ voiding pressure studies

$318-328

$107-108

51729

Complex Cystometrogram w/ voiding pressure studies, urethral pressure profile studies

$344-352

$130-131

51736

Simple Uroflowmetry (UFR)

$16

$9

51741

Complex Uroflowmetry

$16

$9

51784

Electromyography studies (EMG) of anal or urethral sphincter, other than needle

$71-195

$39-79

51797

Voiding pressure studies, intra-abdominal

$113-117

$41-42

 

 

Hospital Reimbursement for Urodynamic Procedures

Any outpatient procedures will be documented through CPT codes. These codes are used for Medicare Ambulatory Payment Classification (APC) group. Ambulatory Surgery Center (ASC) procedures will be paid with lower rates than APC. Outpatient ASC procedures will be paid with 50% compensation of the fee schedule amounts if the procedures are both on the same day. The only exception to this is if CPT 51784 is performed with a status of “S,” as this cannot be subject to multiple procedure discounts.

CPT Code

Description

APC Group

Status Indicator

APC Hospital Payment

ASC Payment

51725

Simple Cystometrogram (CMG)

5371

T

$207-230

$111-113

51726

Complex Cystometrogram

5372

T

$524-566

$293-295

51727

Complex Cystometrogram w/ urethral pressure profile studies

5372

T

$524-566

$205-210

51728

Complex Cystometrogram w/ voiding pressure studies

5372

T

$524-566

$210-218

51729

Complex Cystometrogram w/ voiding pressure studies and urethral pressure profile studies

5372

T

$524-566

$213-220

51736

Simple Uroflowmetry (UFR)

5734

Q1

$91-105

Packaged

51741

Complex Uroflowmetry

5721

Q1

$130-136

Packaged

51784

Electromyography Studies (EMG) of anal or urethral sphincter

5721

S

$130-136

$32-73

51797

Voiding pressure studies, intra-abdominal

N/A

N

Packaged

Packaged

**Status Indicators - T = Significant procedure, multiple procedure discount applies, Q1 = STV packaged codes, APC packaged payment if billed on HCPCS code with “S”, “T”, or “V”, S = Significant procedure, but not discounted if multiple, and N = items and service packages with APC rates applied.

Coding Edits

All guidance on billing is via the National Correct Coding Initiative (NCCI) Manual. The NCCI manual includes all code pairs that can’t be billed together. This is because they are either mutually exclusive or because the code is comprehensive and inclusive of a 2nd code. Each code in Column 2 are not payable if you are under Medicare if you also are reported with one of the Column 1 codes as well. The NCCI edits are always being updated, and multiple edits are being made to urodynamic codes. For a full list of edits and codes head to;

https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Coding/NationalCorrectCodlnitEd/downloads/2018-Jan-Practitioner-PTP-Edits-v24-f3.zip

Column I Code

Column II Code

Edit

51726

51725

Report the Column IN code only: more extensive procedure

51727

51725

Report the Column IN code only: more extensive procedure

51727

51726

Report the Column I code only: HCPCS/CPT procedure code definition

51728

51725

Report the Column I code only: more extensive procedure

51728

51726

Report the Column I code only: HCPCS/CPT procedure code definition

51728

51727

Report the Column I code only: misuse of column two code w/ column one code

51741

51736

Report the Column I code only:more extensive procedure

 

ICD-10-CM Diagnosis Codes

For any reimbursements for Medicare, the procedure must be necessary and reasonable. ICD-10 codes are used to describe which symptoms, signs, diagnoses, and conditions one may have before the procedure. Each procedure that is billed will be supported with a code that represents the needs for the service.

F98.0

Enuresis not due to substance or known physiological condition

N40

Enlarged prostate

N13

Obstructive and reflux uropathy

R33.8

Other retention of urine

N31

Neuromuscular dysfunction of bladder

R35.0

Frequency of micturition

N32

Other disorders of bladder

R35.1

Nocturia

N32.0

Bladder neck obstruction

R39

Other and unspecified symptoms and signs involving the genitourinary system

N32.81

Overactive bladder

R39.11

Hesitancy of micturition

N33

Bladder disorders in diseases classified elsewhere

R39.12

Poor urinary stream

N35

Urethral stricture

R39.14

Feeling of incomplete bladder emptying

N36

Disorders of urethra

R39.15

Urgency of urination

N37

Urethral disorders in disease classified elsewhere

R39.16

Straining to void

N39.4

Other specified urinary incontinence

 

 

 

Conclusion

As stated, there are many ways in which you can claim and report a reimbursement through using this code guide. Be sure to use the CPT codes for physician reimbursements, CPT codes for hospital reimbursements, and to account for ICD-10 diagnosis codes. All of these codes can help build a case for your reimbursement through Medicare or other insurances. Please always contact a medical billing professional before attempting to submit or file for reimbursement. All of this information is based on 2016-2018 estimated reimbursement rates.

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Topics: Reimbursement, Reimbursments, urodynamics billing

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