SPEAKER_02 0:00

On this episode, prior authorization codes. Is there a limit? Also, can you trust AI? Stay tuned.

SPEAKER_03 0:08

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SPEAKER_02 1:10

Welcome to episode 304 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, my co-host Mark Painter, and we want to welcome back Dr. John Lynn. John, thank you for joining us again. And we love having you on and bringing us all these great topics. Welcome, John.

SPEAKER_00 1:28

Thank you so much. I hope to bring some issues that will provoke some thought. Ah, excellent.

SPEAKER_02 1:35

And John is a solo practitioner in Gilbert, Arizona, and he is the founder of the Thriving Urology Practice Facebook group, which I'm sure a lot of you are members of. And if not, John, what do you suggest?

SPEAKER_00 1:50

Well, like you say, if it's free, I'll take three, and this group is free to join. However, it is limited to U.S.-based urology practice, folks. No vendors allowed. So you can let your hair down and speak your mind. Good, bad, and the ugly. So the Thriving Urology Practice Facebook group on Facebook.

SPEAKER_02 2:11

All right. Thank you so much for putting that together, John. I know it's a very valuable resource, and there's a lot of great information there. So it's great for the urology community.

SPEAKER_03 2:21

And always provocative questions.

SPEAKER_02 2:23

Yes. Which is what got us together here today to talk about. There's some great topics on the Thriving Urology Practice Face group being talked about right now. So, John, I'm going to turn it over to you. Get this thing started.

SPEAKER_00 2:39

Okay. No shortage of questions in the Facebook group for sure. This one, well, I'll keep them all anonymous. This is a prior authorization question. And it goes something like this. This is going to sound ridiculous. I'm hospital employed. I have a new front desk person who's being trained on prior authorizations for office procedures. She told me on Friday that she was trained by another office that she always needed to submit two CPT codes for office procedures to obtain prior authorization. For instance, she completed an authorization for office cystoscopy for PPH workup. The prior author was obtained for the cystoscopy and cystoscopy stint removal codes. So we pulled out my office note, and there's no mention of needing to remove a stint or any of the diagnosis codes justifying that. She pushed back and said, that's what she was trained to do in the other office. Am I incorrect in thinking this is absolutely the most ridiculous thing ever? And is it also wrong? Mark, what do you say?

SPEAKER_03 3:57

So I'm gonna say, first of all, unfortunately, it's not the most ridiculous thing ever I've heard. Um so so I think we have to start there. Training is is something that happens, and yes, there have been quite a few things out there that have been a little bit, let's just say a little bit out of left field, and maybe even not even close to the ballpark. So those things happen. But the second question I can answer definitively, yeah, it's wrong. There isn't really a guideline out there stating you gotta have two CPT codes to get a prior authorization. That is not the case. There is, there are guidelines that state that what you're gonna prior off is what you're intending to bill. And that's really the the guideline you should follow. So yeah, the the actual authorization that went through with assisto and assisto stent removal for BPH workup and somebody that's never had a stone or doesn't have a stent in is a bit ridiculous. So from that side, we can grab the ridiculous, and I can understand why she asked the question the way she did. But it is something that ultimately all practices struggle with. You know, when we look at prior authorizations for something like a bladder tumor, where we don't know exactly what size of tumor is gonna be removed. Oftentimes you do authorize more than one CPT code for essentially the same procedure because the codes vary based on size. Sometimes you go in with the idea you're gonna do one thing, but there might be something else related to the procedure that you're gonna need to do as well. And you author those additional codes. So it is important to understand the orders. It's important to understand what the condition of the patient is, and that's really important for the physician to communicate well with the prior authorization staff. And it's a great idea for the office to have some protocols and procedures in place for what needs to be authorized surrounding any one particular procedure in general. Not everything fits a protocol, so it's a good jumping off point. And again, goes back to what is the physician or the APP, the clinician, communicating what needs to be done, and that's what needs to be authorized. The correct diagnosis codes need to be in there. That's the other part of this. And I can tell you, I've had a couple of conversations recently with folks that are looking at the new AI-assisted virtual authorizations that are coming in as a regulation starting January 1st. And certainly we've got some new issues in the proposed rule that talk about needing to be able to accomplish these virtual authorizations in 2027, or at least one, making a full round trip as part of your QPP. So we're gonna watch this entire process evolve. Um, we've the first foray into all of this really was what we saw with the program Medicare rolled out not well for prior authorizations. So we've got to really take a look at what we're doing documentation-wise, because the new virtual or AI-assisted prior authorizations, that program is going to tap into the EHR directly to provide justification for the procedures that are ordered. So I think there's a lot that really we're gonna need to unpack over the next period of time. But today, as we look at things, you need to make sure that your prior authorizations are valid, focused on what's being done, and cover the circumstances that may happen in the operating room or the office.

SPEAKER_00 8:23

John, questions, comments? In this case, this physician is asking about procedures, authorizations for procedures to be done in the office. So I'm wondering, gosh, that's a lot of extra work for this lady to perform prior authors for not one code, but two different codes. And there's really no, unfortunately, no justification for doing the extra work to get the additional CPT code. If there's no justification, how can you potentially bill for that code? That's number one. And number two, that's a lot of extra work that doesn't need to be done, and then she can be doing something else. So this boils down to so much of medicine, which is we do it this way because this is the way we've always done it, also known as status quo bias. It is pervasive in medicine, unfortunately.

SPEAKER_03 9:19

Yeah, I agree. And the other thing we probably should mention while we're on this topic and office-based procedures, is a lot of you are in heavily managed care areas where referrals make a difference. And referrals come in with from primary care with certain CPT codes authorized for that particular visit. That's an area where you may need to think about talking to your primary care physicians, your high referral sources, about appropriate levels of codes, like a four versus a three, whether or not the patient with BPH may need a CISTO on that first visit or a catheterization for a patient in retention. So those are the types of things that you might also add to your mix to save you a little bit and the patient time and effort relative to those referrals.

SPEAKER_02 10:16

All right. All right. John, what do we have for our next topic?

SPEAKER_00 10:21

Yeah, speaking of thank you for the segue. Speaking of catheters and retention, we the the next question is somewhat related to it. Shall we start?

SPEAKER_03 10:29

Yeah.

SPEAKER_00 10:30

Let's do it. Okay. Second question. Our offices, our office supplies were audited by Medicare a few months ago. And they took an inventory of all the supplies we had in our office to confirm we actually had the supplies for which we charge Medicare. The Medicare representative supposedly told my practice manager that we are incorrect to code any A-codes for DME supplies in association with any procedure codes. After doing research on this matter, according to ChatGPT, we are allowed to charge A-codes to Medicare, but only in association with chronic slash permanent conditions. Is that correct? And the poster also said that I find this topic of billing for A-codes remarkably confusing and would appreciate some input. Maybe the painters could dedicate a portion of a podcast episode to this topic. Ask and you shall receive.

SPEAKER_03 11:36

Well, this one's an interesting topic that we haven't covered for a while. So I'm glad it came back up. And when we look at this topic, there I think we can actually look at a couple of different things relative to the answers ChatGPT gave, as well as the rules surrounding what you can and can't bill for. On the surface, if you don't really ask the next question, ChatGPT's answer is not 100% incorrect. The problem is, what the ask or didn't ask is what are the nuances on what can and cannot be billed? So ChatGPT is correct. A codes are applicable to permanent conditions where there is a replacement of a bodily function. The problem is they are not covered by Part B Medicare. They are covered by Part D Medicare and they have to be processed through DME. The supplies and the reason that the Medicare representative incorrectly stated with any A code and any CPT code, the reason that Medicare representative, who ChatGPT gave a very narrow answer to a very specific question, is that CPT codes and the practice expense include supplies provided by the office during a procedure. That's why you get paid more in the office than you would in the hospital or ambulatory surgical center, or that payment to the office is increased because those supplies are included in the practice expense. So when you look at all of this, the physician office really cannot bill most A-codes with the CPT code. Now we do have some exceptions. We have A-codes for PET scanning, we have which is a supply issue that may have some A-code payments. We have Sysview, which has an A-code that can be reported in the office as part of a blue light cystoscopy. And then, of course, we have seeds, which are A-codes, but those fit into a totally different category than catheters and leg bags. Catheters and leg bags, those are only covered under home use for DME for a chronic condition, like chronic incontinence for any one of those patients. And those codes are processed under a DME license and can only be paid to a DME supplier. So if your office doesn't have the capability to bill DME or part the DME Medicare, you are not able to actually charge those A codes to the patient for those supplies that are used. And importantly, even with a DME code, the catheter that you place in the office and the leg bag that you attach to that catheter, even though the patient wears it home, is included in the 51702 if you use that code. So it is confusing, but in general, you can assume that your supplies that you use with your procedures are not separately billable, with very few exceptions for those odd cases where you have maybe an implant or a die. Those are the only differentials that we really see in the marketplace. And those dyes typically are not billable unless you're used, you're not using a radiology code. So there's there's a lot of nuance there, and I don't think we can go into every situation in this podcast.

SPEAKER_00 15:51

That's okay. We can go into one or two. So in the question, the commenter also asked, in this temporary situation, a new patient comes in for office visit, BPH, actually, my first patient today, with acute urinary issues, and find you do a postvoid residual ultrasound and it showed greater than liter and decide, okay, it's time to put in the catheter. The patient agrees, you put in the catheter and send the patient home with a leg bag. Can you charge the standard latex folio catheter, the A code A4, and the leg bag A4358 with the foley insertion? And the answer is no, because that fole insertion code 51702 includes the supplies, the practice expense supplies. So I hope that is clear. Mark, what do you say?

SPEAKER_03 16:46

Yeah, that's exactly right. And that's a great example of those supplies were used as part of the procedure in the office. Essentially, band-aids, bandages, catheters, tubing, that stuff that you send home with the patient because you put it there. That never qualifies for an A code.

SPEAKER_00 17:06

Okay. Here's another one. This this poster also asked chronic slash permanent situation, a guy with a neurogenic bladder, permanent urinary retention comes in for a scheduled monthly or every six week fully catheter exchange. You supplied the materials, et cetera, just like the first temporary example. What can you build?

SPEAKER_03 17:30

So the actual catheter that you took out and put in a new one in the leg bag that's there, not billable. Even though the patient has a permanent condition. Agreed. If you have a DME supply code, supplier authorization, you are a DME supplier, and you gave the patient an additional two catheters and two leg bags, then those could be coded, but they have to be billed to DME. They cannot be billed to your Part A Mac. You have to have a totally separate supplier number, and it's an entirely different process to get those two paid. So again, it's about asking the right question and to ask the full question before you get the complete answer. And it'd be interesting to see if ChatGPT came back with the right answer with a few more questions.

SPEAKER_02 18:25

Would you okay, what if you wanted to give them the two catheters and two leg bags? You're just eating that cost, or is there any way to get reimbursed from that? You charge the patient.

SPEAKER_00 18:35

Or more more commonly, what if the patient requests an additional leg bag? That's more common.

SPEAKER_03 18:42

My advice would be to send them to their DME supplier or their home health care. Exactly. Whichever of those folks are there, there is not a good way to get paid for those things. It's one of those areas where I just would advise you to steer clear of that process.

SPEAKER_00 18:59

And also with a shortage of physicians, urologists, do you do you really want to clutter up your office with catheter exchanges? That's the real question. Yeah. Great question.

SPEAKER_03 19:11

That is one of those things that, as we've talked about time and time again, there are so many patients needing urology care. We've got to change the habits that are out there. I mean, it's I I I understand that it's a little less personal for the patients who would like their support from their urologist that they're used to getting. We just unfortunately the system doesn't have that built into it at this point in time. It's a it's going to be a tough change for a lot of those repeat visits.

SPEAKER_00 19:46

One alternative is that the practices, if they're not already doing it, should adopt and fully embrace telemedicine so that the physician can still use his or her time much more efficiently and yet still maintain that connection with the patient.

SPEAKER_03 20:02

Yes. And it and it's a good point, John. I mean, even though you can't through telehealth do a catheter exchange, you can certainly still stay connected to the patients and their condition and have somebody else do the catheter changes. Those are not that lucrative across the board. They're when you really add it up for time. Yes, there is a top-line revenue, but is the net there? I think that's the other thing you got to look at. That's staff, time, material that really is not a big margin procedure.

SPEAKER_00 20:37

Well, I'm not going to go into modifier 25, even though with these routine scheduled catheter exchanges, there's really no, typically no additional ENM. Just like a LHRH injection, there's really routinely no additional, typically no additional ENM service provided. But once in a while, you probably may be getting an ultrasound to check the upper tracts, or asking the patients, does he want to continue on an LHRH? Has there been any any changes? Some of sometimes those are billable ENM procedures, but most of the time it's just a straight catheter exchange. Now, those ENM procedures or ENM services can typically very easily be done via telemedicine. Another plug for telemedicine. Yep.

SPEAKER_03 21:28

And a good one. And one that could be even more important next year if they decide to cut the reimbursement for ENMs with modifier 25.

SPEAKER_00 21:35

So Yeah. Boy, that's huge. Anyway, comment for those listening. Make sure you comment to CMS about your thoughts. Yes.

SPEAKER_02 21:45

All right. Do you have another example, John, that you want to go over, or are we good with this example?

SPEAKER_00 21:52

Well, I think with the second question, there's another potential example about BCG installations, and I think the answer is pretty quick. Clear. What about BCG installation and patients with bladder cancer? Can you fill for the straight catheter and the tummy syren juice for the installation, or is the cancer considered a temporary diagnosis, even though the patient will undergo surveillance histoscopies for the rest of his or her life?

SPEAKER_03 22:16

Yeah. So that's you kind of actually touched into two different things. I think we can go back and with the theme of the A codes, all of your CATs, your installations, all those things are included. The BCG as a drug is separately billable by rule as a buy and bill drug. So you're going to use your J code for your BCG. So we can't bill for those supplies. But it seems like underlying the question there is what about billing the straight cath? So that's one of those things that NCCI, of course, includes a catheterization with an installation because how else is the drug going to get to the bladder? So we can't bill for that straight cath as a separate CPT code. That's where the bundling edits come in. And that's probably that's true of most urology procedures, that the catheter or catheterization insertion, catheter insertion, is in fact bundled into most codes because it is typically a part of a urologic procedure, even in the office.

SPEAKER_00 23:27

In essence, when whenever a patient comes in for that routine BCG installation, the first line on your claim should be encounter for antineoplastic immunotherapy to Z501.12, and then you pick the drug of choice. So you bill for the drug of choice and also the installation code. And the installation code is the installation code includes the supplies that you use to perform the installation.

SPEAKER_03 23:57

Correct. And the catheterization.

SPEAKER_00 23:59

Correct.

unknown 24:00

Yeah.

SPEAKER_02 24:01

All right. All right. Before we wrap this up, I got one more question for you. And that is, you know, kind of what came in with this second question is AI. We have a lot of people relying on AI for answers for things. How do you responsibly use the AI use AI when you're looking up, when you're doing the research for these type of questions? Mark, you mentioned that it got close, but there still wasn't the second question answered. And that's, you know, that that that kind of echoes what we've been saying is yes, it's AI is a great tool, but it's a tool and you have to verify.

SPEAKER_03 24:43

Yeah, it really is. And that is one of the things as we all are starting to work with AI, it's important to understand how to query. And it's just like in many ways, much of it is like you're doing research on Google or looking through the web or looking through LCDs and LCAs. You really need to understand the bigger picture of what's out there in order to ask all of those questions. So I've generally made it a general rule for myself when I ask AI to do something and I get back the answers. Number one, I'm gonna limit its sourcing because that's the other piece that's out there. It as you look at where AI pulls its information, it could come from Reddit and be stated as a fact. And that is something that may not be even close to reality. It just answered the right question. That that filter is not there. So you want to make sure you do a good job of limiting the sources from which the AI can pull its information. I would encourage you to ask it to provide the sources that it used. And then you've also got to be wary of the question that you don't know, and that is for this one, you know, how many people would actually know or understand that DME and chronic supplies are not really part of Part B Medicare, but are part of the durable medical equipment processing. Now the Macs process it, but the Macs actually process DME for different parts of the country. So Neridian may actually pay DME supplies in New York, and that and they don't pay for standard physician services in New York. That's a different Mac. So it's an entirely different system, and that one's a little bit tougher to nail down, but you might want to ask the questions like, are there any circumstances or regulations that would prohibit me as a physician providing services to the patient in the office from billing these A codes? So ask that extra question, whatever you can think of that might give you a different set of information. And again, limit the sources.

SPEAKER_02 27:32

John?

SPEAKER_00 27:33

Yeah. The in the first question, the Mac, apparently Mac represented. Now keep in mind this is secondhand information. This physician heard it from his office manager who heard it from the Mac auditor. So the Mac auditor says any and all and always. You anytime someone says that, you always have to question the answer. Secondly, I recently, actually, someone DM'd me recently and asked, hey, did the global period change for 52356, you read roscopy with laser litherphy and stem placement? I heard that it's now 90 days. And I asked AI, and AI said it's 90 days. So I said, What? Of course, looked it up on Chat GPT, Claude, Mannis, Perplexity. And sure enough, some of the sources are telling me that it was a 90-day global. And that could not be further from the truth. So I did a video about it in the Thriving Ulogy Practice Facebook group, debunking. And what I did was I went to the primary source. Instead of trusting Reddit post or Wikipedia post, I went to CMS's guidelines and said, and I looked up the table and says, yep, it's still zero day. So I don't know how AI got this wrong. Trust but verified. That's the thing. And it's it's so difficult because so much misinformation out there and chat GPT and AI is so easy to access, but you have to understand, I think, some of the basics. I think that's part of the reason why we go to school. So we understand the fundamentals. And then you build off of the fundamentals instead of just trusting a source you hope is benevolent, like AI.

SPEAKER_02 29:22

Great information. So hopefully you take that to heart. And when you're asking AI, you know, really think about it as a tool and trust but verify. All right. Let's wrap this episode up. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com forward slash PRS network for specials for our listening audience.

SPEAKER_00 29:50

Hey Scott. Yes. Talking about trust and verify, where can practices get some of the fundamental information and education about this coding billing revenue cycle management so that they could better their game and not be fooled by chat and AI?

SPEAKER_02 30:11

One of the best places that you can go is our Urology Advanced Coding and Reimbursement Seminar. This these are two seminars. We have one in Las Vegas in December and one in New Orleans in January. And the three of us will be there. Mark and John will be presenting a lot of this great information and have they've gone through it, synthesized it, and put it into an understandable, usable format so that you can apply it immediately within your practice. And it's very practical. And the discussions that happen throughout the seminar and the questions that are asked are invaluable because you're hearing different opinions from different practices throughout the country. And if as a practice, you tend to be practicing in a silo when it comes to the information that you have on coding and reimbursement. And that's why the resources such as the Thriving Urology Practice Facebook group, the Urology Advanced Coding and Reimbursement Seminar, these podcasts, our webinars are all very valuable to tap into because you hear different ideas, different perspectives, and you can glean a lot from those different perspectives and incorporate them into your practice so that you can practice more efficiently and you are not leaving anything on the table. That's important, especially as the payers become more sophisticated. You, as a collective urology community, have to band together and work together to make sure that you can adapt to all these things that are happening out there. And you can't do that in a silo. You can't do that without the information and the collective genius of the urology community. So we encourage you to do that. You can go to PRSnetwork.com and right there on the homepage is a seminar registration button. You can click on that and it'll give you all the information you need to register. And we encourage you to join us. Can guarantee you that what you learn there and the investment that you make to attend will more than be made up by what you learn and what you can apply, and you can apply it immediately. The Monday after you get home from your from the seminar, you can put a lot of these things into practice. So we do encourage you to join us there. It is it is really truly a great experience, and we hear that every year. And the the attendees and everybody that that comes there really has a great camaraderie, and it's really fun to see.

SPEAKER_00 32:56

And Scott, what is not so surprising is that I every year I've been doing this for probably over a decade now, almost a decade now. Certainly been attending these seminars for over a decade, but been presenting there for almost a decade. What is not so surprising is that I see the same faces at the same locations every single year. And it's interesting to hear some of these attendees, and they tell me, man, it's so great to hear this again. And not only are they getting these some of the same information, which for me, I needed repeated exposure as I was learning this to finally ink and seared into my mind on how this actually works. Not only that, some of the best information came from the attendees. Some of the attendees would say, well, you know what, in New Jersey or in Florida, we're doing X, Y, and Z. And you thought, oh, wow, I never thought of it that way. Maybe I should look into it. Or they started doing a particular procedure or have a particular pathway that you never even thought about. Like you said, collectively, we are better together. And we often we do actually, a lot of us work in silos. We work in our little practices, the little groups, and we don't have exposure to outside information. So the Thriving Urology Practice Facebook group is awesome. Also, the urology advanced coding and reimbursement seminar. There's something about face-to-face in-person discussions that is so much more intimate, and people I think are more willing to let their hair down. Also, we can all commiserate together in those sessions, which happens a lot. So true. It's therapy.

SPEAKER_02 34:41

It is. And getting together with like-minded people that can understand your woes, you know, exactly. That's a great place to great place to be. So all right. Okay, let's get some final thoughts. John, final thoughts today.

SPEAKER_00 34:54

You know, I after 12 years, I finally got a new car, and I had no idea that technology has advanced so much to make my life easier. There's lane keep assist, lane follow assist, blind spot warning that I didn't have in my old Subaru. And also ventilated seats. I mean, creature comforts to make my driving experience that much better. Well, why do I tell you about my new car? Well, because coding and billing is similar. Running a urology practice is similar. You can continue to drive your old 2015 Subaru, or you can upgrade to a newer car with all the technologies. Encoding, billing, practice management is the same thing. And what is missing, the gap, is information. So you have to be open-minded, you have to be willing to learn, otherwise, you will continue to be stuck operating in the old ways and continue to drive in 2015.

SPEAKER_02 35:57

Great point. Mark, final thoughts.

unknown 36:02

Yeah.

SPEAKER_03 36:03

So just a few things on the overall here. I mean, we've covered a a a couple of different topics, but we've touched a lot of different things. One being as we started off in the prior off side of the equation, I think it's been a a theme now for the past few years. That the work before the claim goes in is now not optional. It's essential. And it has to be done correctly. And it's an administrative headache for sure. And it's not going to get any easier. So I really encourage you to take a look at everything that happens prior to the visit. Get your prior authorizations, double check the patient's insurance, make sure you're collecting the co-pays before the patient goes back. All of those things that right now in the standard urology practice end up on the as the responsibility of your front desk staff who are very often overloaded in what they're trying to do. So take a look at your workflows and your staff in the front and make sure that you've got those people well trained and they understand what's going on. But the other part of this that is perhaps even more important overall is the actual clinical note. These clinical notes are being looked at routinely. Down coding, audits, medical records request. It's all part of the process at this point in time. We used to all we always told people it's not if you're gonna get audited, but when. And now it's you might you should really assume that every single chart that you bill for is gonna be looked at. So you want to make sure that is all clear, clean, and part of your consideration in each and every case. You really need to make sure that's part of the process, making sure you've got that documentation, your orders are clean, the office can understand your orders and get the right codes. All of that's really important. And then when we talked about AI and we talked about A codes and those types of things, this is a complex system and it is messy, and really having that expertise in-house is important. It's also important to have support outside of what you're doing. Make sure you're checking coding today, which grabs primary sourcing for procedure globals and bundling edits, all of those things need to be in place. Make sure you're looking at the primary sources from Medicare for your information. And you've got to broaden your thinking a little bit because this complex system touches a lot of different rules and regulations. And so when you're using tools like AI, make sure you ask those questions, dig into the sources, and verify all of the information you get. And as those of you who are looking at new and different things and what you're trying to do, make sure that you understand the coding and documentation that needs to be done for those new tools that you're providing. And then I'm going to close last with what we talked about last time with telehealth. The practice of health of medicine is evolving very quickly. And we all need to adapt from the documentation, from the actual office flow to actually who we see and who we want to see. All those things need to be looked at and they need to be revisited. You can't just sit in a bubble and hope to remain a functional and healthy urology practice.

SPEAKER_02 40:16

Well said. All right. That's all we have for today. John, thank you for joining us again. We love having you on. We thank you all for listening. Take us out, John.

SPEAKER_00 40:29

Happy coding and billing, and see you in Vegas and New Orleans.

SPEAKER_01 40:36

Thank you for listening to the RD Coding Remembers Podcast, where we help your authors understand maximized income and time.