On this episode of Billing for Injections and Installation, the importance of NDC. Also, double appeals, how do you deal with that? Stay tuned.

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Welcome to episode 307 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. And have a lot of this stuff coming up, a lot of this little details that the payers are paying attention to. And how do we deal with this? So we got a couple more examples on this podcast. One, as I mentioned in the intro, one, we want to talk about the importance of the NDC number and when you're doing injections and installations and why that matters and how to deal with that. And then and then next we'll after that we'll tackle the double appeal. And how do you deal with that when you know you're right? And how do you navigate that? So, Mark, we've had a lot of discussions internally on this. And and let's start with the first topic, the NDC numbers and the injections and installations. Why has this become a topic and how do you deal with it?

So I think there's several different things that are happening right now in our marketplace that are making billing for drugs more complex and definitely more difficult to navigate. So as we look at the introduction of biosimilars, that's one of the things that's driving a lot of these questions as we go through the process. And then the second part is the billing of things like interferon that are provided by compounded pharmacies or interferon things that we're using now in lieu of or in the face of the BCG shortage, and as we're really trying to deal with some bladder cancer stuff, these are kind of the two things that are driving things. That ultimately, if we've got a J-code and we've got an appropriate NDC, whether it's a generic or a brand name, we've got a pathway to bill and we've got ASP plus six pricing. And when we start looking at shortages and as people start trying to find solutions for their patients, we've looked or we've seen now a lot of compound pharmacies coming into the marketplace to deliver some of these. And most of the Macs have policies that don't allow for a standard J code to be used for compounded for drugs from compounded pharmacies. So when you look at that process, you really have to take a little bit of an extra step in digging through to find how to bill these drugs appropriately and where they fit on the reimbursement side. So it takes a little bit of extra work that you need to do up front before you give the patient these drugs. I mean, once you've given them the drug, obviously you've incurred the cost and now you're in the fight mode for all of this. So you really need to take a look at what you what pathways are available to you because it's not just as easy as slapping a J code on and using an NDC number for an existing generic or a different code. So this is something that we'd encourage you all to really look at. Now, some of the biosimilars, they're getting FDA approved. These are more nationally available, and ultimately they are getting assigned Q codes. So this is something that you want to make sure with your manufacturer where you're getting those biosimilars, that you're really taking a look at whether or not there's a separate Q code specific to those biosimilars, which often have their own drug names, and the associated NDCs. And then beyond that, look to see if those are allowed by the plan that you're giving them to. And we briefly discussed this during, I think, one of our webinars recently, that those biosimilars are difficult sometimes because, in essence, the physician doesn't necessarily know, or the qualified healthcare provider doesn't necessarily know which of the biosimilars are covered or paid for by that particular payer. So one of the things you want to look at is how you order from the clinician side, making sure that you are ordering an ExDiva or a ProLia or appropriate biosimilar, making sure that those orders are flexible enough so that your billing team and your revenue cycle management team, as well as your clinical team, can deliver a drug to the patient that actually is covered by that particular payer. And then the billing needs to be matched to whichever drug you used. You obviously, with any drug, want to record very carefully the drug, the lot number, the units, any discarded amount, all of that is essential for any coding that goes out the door. So you need to have that backup in the process. So you've got to have a little bit of a team behind you to make sure you're giving the right drugs to the right folks, making it, once again, a lot more difficult for not much more money, but it is unfortunately the way it is right now. But now the other side, the compounded drugs that are coming in like interfere on, those have different formulations, and we don't have necessarily those Q codes. And in working with your compounded pharmacies, we need to make sure that they're giving you accurate information that matches the drug that they're delivering. We need the NDC numbers, we need to make sure that you're using unlisted codes for those compounded drugs for most of the Macs, if not all of them. And watch where the pricing sits for those if you can get a hold of those. So if you can't actually get the information ahead of time, this is an area where you might want to go slow, do some experiments, do the installation, get the bill. Now that you've got all the numbers, see what the reimbursement is and whether or not it matches. So that's just one of the couple of the drug problems we are having that are out there. And the other one, of course, that's popped up recently is drugs that are going up in acquisition cost, but not seeing the same results in the ASP plus six. As you all know, cost of drugs changes. And you're certainly going to want to watch what your acquisition is. Now, the ASP or the pricing that Medicare assigns may not reflect that acquisition cost because that ASP is based on a rolling 12-month. And so you get behind, and ultimately you're going to have to make some tough choices on whether or not you want to keep giving a drug at a loss, or maybe it's time to look at alternatives to how the patient supplies the drug for those treatments. And there's the moral side of this, I think, is an argument that every physician deals with. Certainly, blah, the cancer treatment drugs are ones that you've got a little less leeway on that you really need to bite the bullet and treat your patients on. But some of those little more cosmetic or maybe those can wait, those are things that, yeah, it does put your patients in a bind to have them navigate the process of getting that drug and delivering it, gives them a little bit more work to do, but you can't afford to keep giving things away or paying to treat your patients. So it's a tough balance. Everybody's got to figure out where they sit on that scale. But recommend that you really build your internal policies and procedures to deal with each one of these issues. Bring a team in or a couple of folks that really understand the navigational aspects of biosimilars and Q codes and somebody who understands compounded drugs, and then, of course, your overall financial team to really take a look at what you do with pricing differentials. So it's not just the old standard, we can grab the drug off the shelf and give it. It's now gotten a little more complex, as everything seems to be doing these days, unfortunately.

I got a quick question on the compounded drugs and the unlisted code. What's the backup documentation you need for that unlisted code and the drugs that were compounded in there? How do you how do you do that?

So, one, you want to make sure you can get any labeling that the compounded pharmacy gives you. And then the second part is yeah, you want to get your invoices together and keep those. If you're we're making a case for a payer for different reimbursement than what you get, that's going to be an important piece of this. And you want to make sure before you do any of that that your compounded pharmacy is a legitimate outfit with an understanding of how to make sure that they're on the list in a covered situation within the state you're providing the drug. Ray, comments, questions?

No, it just uh represents that moral dilemma that is getting more and more difficult as time goes on as to where you're going to pay to treat a patient the way they need to be treated or not.

That's tough. That's a tough position to be in. All right. Okay, anything more to add on on the compounded or other installations biosimilars, or we should we move on to the next topic?

We can go ahead and move on. Well, we'll probably have to touch base on this again as we start to see things go through, but that's kind of that starting point we can deal with. And certainly if anybody is having success or failures out there, let us know so we can share them.

Yeah, that's so important. We want to make sure that we're gathering what's happening out there and sharing with everybody else so everybody can be prepared and deal with what's happening, what's coming, and all that. It it does take the urology community and the village, especially in this day and time. All right, let's move on to the next one. Okay, so we said in the intro and talked a little bit about double appeals. What if you actually know you're right and you're still getting double denials? You know, and what's how do you deal with that? And Mark, can you give us an example of what why we brought this up and what's happening out there?

Yeah, so recently we've seen a few cases where we've had two services provided on the same day. Now, these are not normal cases, they're kind of out of the ordinary. Um, one of them was a treatment of a bladder stone, where clearly the documentation showed that the physician went in knowing that there was a bladder calculus, that bladder calculus was treated. The patient also had uh renal stone, and then that was treated. And so both the code for the bladder stone treatment and the stone, the kidney stone treatment were billed, the 52356 and the 52317, because it was a larger, more complicated bladder stone. And the payer originally denied the claim, even though all the modifiers were right and the diagnosis pointers were correct. So the documentation was sent in, and a denial came back after documentation review. So this is one of those areas where, I mean, everything looks correct. Everything should support the billing of both of those codes. We've had a couple others that maybe are a little bit more on the on the grayscale, maybe a lift uh an S wall in which there is a large stone fragment left in the ureter that then a ureteroscopy is used to treat, where you've got a separate approach. It's not a normal inclusion process. That one we could look at a couple of different ways, but either way, these are situations where the payers not allowing the work that was performed. So the second one, we could have looked at a 22 modifier for the 50590, but really with a separate approach, felt it was more appropriate to look at the 52352 and the 52332 for the stone manipulation and then the stent placement afterwards, both done retrograde because it's different approaches. So in it in each of these cases, as we go through this process, it's difficult to go through this. Now, obviously, the case where we're a little bit more gray trying to push to the 22, maybe the right move because that was cleaning up after the the S wall, but the stent placement should have been paid. So that one we're gonna keep fighting for. So that's a different issue because we did that retrograde with the stent placement. That one should be paid and was bundled. Now the stones, the two different stones, the bladder stone and the kidney stone, that clearly should be paid. So when that second denial comes back, the second would appeal it again, and this time with a cover letter. A lot of times we appeal the first time just with the documentation, believing that the documentation would support what's going on. But what you're gonna need to do in that second level appeal is add in medical necessity and context. So you really want to provide a little bit more of an explanation and a cover letter as to why things were done the way they were and why the medical necessity was there and clearly explain to the payer slash computer slash reviewer out there why these two are clearly payable. In the case of the stones, the bladder stone existed prior. The diagnosis supports this, as to does the documentation. It was medically necessary to appropriately treat the stone prior to treatment of the kidney stone. The modifier and the system does allow for billing of both codes under circumstances like these. This is an unusual case, and we should get paid for both. And then it may take after that peer review or a higher level appeal. So it is important to stay on these things. I know they're unusual cases, and ultimately, as you look at what you're fighting for is not just that code, but also letting the payer know in no uncertain terms that you know what you're doing from a coding side, you know what you do from the billing side, and you are going to be a pain to get paid for what you're owed for the work that you did. Now, obviously, that documentation needs to be there to make sure that you're pushing those that extra mile, but it is important to do, I think, even given everything else that everybody's got going on right now with all the down coding and the ridiculous denials and the rack audits and the UPIC audits, it's gonna be tough, I think, more than anything else, to just allocate your resources appropriately. And that's where it's really part of the equation that you need that closed loop with the clinician and the revenue cycle management team in lockstep to help work through these things as quickly and efficiently as possible.

Do you notice when you are working with your clients and uh working with various pairs? Do you notice that when you first start working with them there may be a higher frequency of the of denials? And I know the double double denial is on unusual cases that that happens, but do you notice that if you are paying attention and you are doing these things, the frequency of these type of denials does go down? I mean, are you noticing some different behavior from the payers based on you taking over an account and working more diligently than maybe that account had been working before?

I have to admit it's an ebb and flow right now. The ultimately we are. I mean, a good example is downcoding. We fight the down codes, we get the appeals overturned, and or so the appeals are supported, and we get physicians, individual physicians, removed from the down code list, and that stops for a little while, but then it starts up again. So it's I mean, we get small reprieves instead of big reprieves like we used to, but but they we do get some small reprieves, and so it's I I think in the end the issue boils down to they've got more tools to build that are not as expensive as they used to be to throw at you and hassle you out, and they're trying to wear everybody down. And it's just so right now I'd have to say sort of.

Well, you kind of look at it and say as their denial cost is coming down, that eventually it will hit a human being at some point, and that cost still is a higher cost than the automated denials. And so eventually you would think that it would catch up, and if they were doing their most efficient work, they would avoid Going after those practices that are costing them more human capital. I mean logic. That's logic there, but it's a good it's a good theory. It is a good theory. And I would like to see Yeah. And I understand why you're you're continuing to do it because it it's the right thing to do and it's hopefully the end game is really the outcome that you want it to be.

Yeah, I mean it's it's a resource consumption argument, right? That always comes into play on both sides. And so we've got to get more efficient on how we fight these things as well. So it's it's both. What can you do on your side to accurately and efficiently fight? And ultimately who's gonna win the the the attrition battle? Who's gonna give up first? It's the Brinksmanship that's there. It's I and who knows where it's gonna end up. I mean, right now we're early stage in a lot of this stuff, and yes, hopefully someday we get to a point where this one way or another gets resolved. I mean, it's probably gonna take a few lawsuits, and I mean it's gonna it's probably gonna take every tool in the box to deal with the downcoding issue. The other denials and the UPICs and the racks and those types of things, right now, those are tougher to really slow down your commitment, your resource commitment on, and they're coming. And so it's important to build your teams and again efficiently and as effectively as possible and thoroughly respond to all those things because what we're seeing is an escalation across the board. If you ignore them, then it leads to a next level, and then a next level. So the part on the physician side is maybe not win, but to actually stop it from escalating. So it's more stopping the bleed now than trying to actually win the ball game. So we got to figure out how to survive this period and get to the other side where we get closer to being on the offensive instead of right now just living on the defensive side of this overall craziness that's in the market.

Yeah, and unfortunately, the two groups that suffer the most are the physicians and their practices and the patients.

Yes.

Ray, thoughts, comments? Well, it's interesting how things are changing. Back in the earlier days while I was in practice, we had some examples, and I personally did, of insurance company nibbling away and not paying the right thing. But by appealing, they stopped. And then back in the HMO Gogo days, we had some very flagrant examples of an insurance company that just kept increasing denials to a group that that were not tending the shop and didn't pay any attention to their denials. And now, Mark, as I hear you talking, it sounds like that escalating of denials may not be working that way, but the audits are the thing they're using to go after. But it's the same thing, them trying to keep your money. Yep. All right. I did have one other question. What is your take on when it's time to escalate this on up, or do is this the time to discuss an ALJ appeal, or do you want to save that for later?

So I mean, pushing up to the ALJ is always an option and always a consideration. And the my biggest beef right now on the ALJ side is the ALJs are behind. So it's not like you can you can actually get to an ALJ quickly. It's a long game push at this point in time. So I mean it's still being right is being right. And it you know, in the end, it depends on what it is and how far you need to do it. If there's some pattern billing behind it, that's an issue. So it's it's I I keep it's a balance, I think is the best way to put it. But it is something that in the end, my from my perspective, it's worth doing. It's worth taking your time and making sure you're doing three, so especially if they're big issues.

All right. Okay, well, let's wrap this episode up here. 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. Also, we want to make you aware that the Urology Advanced Coding and Reimbursement Seminar is coming up very soon in December. And you can go to PRSnetwork.com and right there on the homepage, you can select the option to go check out the seminars and the pricing. We encourage you all to join us at that seminar. We talk all this stuff, and really it takes that community and that collective genius to help make this fight more fair, I guess. So we want to really take all that information and arm everybody with it that that attends and do the best we can so that we can get paid for everything that we do. So the all the practices out there, you want to make sure that you're collecting for everything that you're providing and all the services that you are providing. Okay. Let's get some final thoughts. Mark, final thoughts.

Yeah, this is it's frustrating and it's I mean, it's just a burden right now with a lot of this stuff that's going on. And it is hard sometimes to wake up and say, man, I'm fighting a good fight. I want to get up and fight it again today, but we gotta keep doing it. I mean, there's just it's just a problem at this point in time. And I'd love to tell you there's an obvious solution out there. There's an obvious way to really get through this, and we'll get there. And I think there's some tools in development that we can start helping with, and we're really working hard on those things, and I know others are too, to see what we can do. And it's there's a lot of focus on making things less administratively burdensome out there with a bunch of products coming in the marketplace. And those are things that ultimately are driving the defensive posture of the insurance companies and give them a leg to stand on as they watch the development of some of these new tools and the new approaches to documentation and coding that that are out there. And it doesn't mean you can't skip this the day-to-day block and tackle. And it does mean that you have to pay attention to your documentation, the LCAs and the LCDs, knowing that there's gonna be some questions, there's gonna be some lookbacks. It's just right now the way the game is played, and we've got a little bit of work to do to catch up to where the payers are right now, and that's kind of unfortunately where we are. But I do think we'll get there. And that's the the ray of hope I'm gonna give you is that there's a lot of work, there's a lot of smart people working on this, and we'll get there. But boy, right now it's a lift.

All right, let's go to our ray of hope. Ray, any thoughts?

Well, the only thing I can add right now is restating the obvious, and that is as computers and bots and all of this are coming to more in, the the detail is getting even more and more important, and it all states starts with the documentation. Indeed.

All right, that's all we have for today. Thank you all for listening. Thank you for listening to URL Coding members to the podcast, where we help you out just understand maximized income and efficiency to the time energy efficient and afterlife. So you can find 202 on Spotify under Square Total.