Practitioner Spotlight on Independent Urology

Dr. Greenstein Discusses Billing and Coding 

Interview conducted 6/12/2023 

Marc Greenstein, DO
Urologist
Advanced Urology
Sandy Springs, Georgia

LUGPA: Why is billing and coding unique or especially cumbersome in Urology?

MARC GREENSTEIN: I do not think coding is unique to Urology nor do I think it is cumbersome specifically to Urology. Coding is unique and cumbersome to all physicians. It is an overwhelming system with numerous rules, subsets and exceptions. Every physician should learn about medical coding to some degree so they know the billing aspect of what they practice. There is a difference between seeing a very simple patient but spending 45 minutes with them and seeing an extremely complex patient but only spending 10 minutes with them. Additionally you have to know the rules and codes of procedures. Any person who is doing a surgery or procedure should know something about bundling, operating on different parts of the body, and doing numerous procedures at the same time.

LUGPA: What does reimbursement rate mean? How is billing and coding related to reimbursement?

MARC GREENSTEIN: I am not sure if anybody knows what the reimbursement rate is. Every physician, whether they are in private practice or employed, has a contractual rate with an insurance company. It is only government run insurance that essentially gives everyone the same rate across the board. But that can change depending on the location in the country. With private insurance, a physician may get a certain amount from that private insurance for a level 4 office follow-up visit but another physician down the hall may get 20 percent higher or lower from the same insurance company for the same level of visit. So based on this contract, a physician will get a certain level of reimbursement based on the bill (code) that is submitted to the insurance carrier.

LUGPA: What do you think is the biggest issue with billing and coding for urology that private practices are facing today?

MARC GREENSTEIN: There are probably many big issues, but the one that is most problematic is that insurance companies do not want to believe the level of code that we are submitting. For example, if I see a patient for a ureteral stone causing hydronephrosis, prescribe tamsulosin and ketorolac, and schedule that patient for surgery, I would use diagnosis N13.2 and submit a level 4 office visit to the insurance company. We are seeing immediate denials or down coding to a level 3 office visit and the insurance company requests our office notes proving the level of care that we have provided. This essentially increases our workload and delays reimbursement time.

LUGPA: Can you explain how coding in urology overlaps with oncology, pediatrics, endocrinology, gynecology, gastroenterology, etc. How does this affect your net income?

MARC GREENSTEIN: Any field that combines with procedures can affect your net income. An internist, pediatrician, family doctor that does nothing but E&M visits will not see a change in their income from doing procedures. Any field that offers procedures will see a change in income based on doing those procedures. Each procedure has its code and RVU, relative value unit, and compensation. I have never compared notes to my other colleagues in different fields but I can only guess that someone who does a lot of procedures will see an increased income from those procedures. I think it comes down to basic math. If a pediatrician sees 20 children in a day all at level 4 visits all from blue cross blue shield, that pediatrician can pretty much calculate their income for one day. If a urologist sees 20 patients in a day, but 5 of those patients needed cystoscopies along with an office visit, 3 of those patients needed testosterone pellets along with an office visit then the procedures will increase their net income. However the urologist needs to make sure they are using the 25 modifier properly. This is the modifier telling the insurance company that a procedure was done in addition to an office visit but the two were not related. For example a cystoscopy was performed for microscopic hematuria, but the patient was asking about medications for an overactive bladder. These are two separate issues and hopefully the insurance company will recognize that.

LUGPA: Why do you feel it’s important for a Resident and/or new urologist 1-5 years in practice to know billing and coding basics?

MARC GREENSTEIN: I feel that every physician should know the business level of the medicine or surgery that they practice. Any business owner, let us say the owner of a T-shirt company, knows how much it costs to make a T-shirt and the price they’re selling the T-shirt for. A urologist or any physician should know what it means to perform a surgery and understand the reimbursement that is involved for that surgery they perform. They should know the application of modifiers so that they can make sure they are being reimbursed for the work that they provide.

LUGPA: Should a resident be informed about how billing and coding is being handled before they take a new position?

MARC GREENSTEIN: Personally I think a new attending should practice Urology for a little while, get their feet wet, understand the aspects of being an attending and then start learning coding. Many of the electronic medical records will also have coding assistance built into them. Just by clicking some boxes along the way will change the level of code provided in an office visit. At some point the urologist should also learn the codes that are involved with their surgeries that are performed. 

LUGPA: There are three main categories for coding: Evaluation Management codes, Procedure codes and Add-on codes? What’s an easy way to understand these?

MARC GREENSTEIN: I do not think there is an easy way to understand these.  I think this is a very complex process that requires years to understand. I feel that the best way to understand it is by constant repetition. It is just like being a resident. You learned things by doing it over and over and over again. Coding is not see-one, do-one, teach-one.

LUGPA: What are some common mistakes in coding that can lead to a rejection of a claim?

MARC GREENSTEIN: Common mistakes would be improper diagnosis codes and inappropriate levels. I am not sure if this is a mistake, but I have also seen insurance companies automatically deny level 5 office visit codes.

LUGPA: What happens when a claim is rejected?

MARC GREENSTEIN: Hopefully a rejected code will be picked up by the coding staff in one’s office or the company that they contract to do their billing. They would need to find out why a claim was rejected and resubmit with either a change in code or level of visit, or may need to submit the office or surgical note.  This requires staff to work to recover potentially lost income. Sometimes these rejections can go back and forth for months until income is recovered.

LUGPA: What does undercoding mean? How does this affect net income long-term?

MARC GREENSTEIN: Undercoding is when a physician purposefully lowers their level of visit in hope of not getting a rejection by an insurance company.  For example, let’s say a physician sees a person for low testosterone, reviews their blood work, prescribes a new medicine, and requests blood work in 3 months. This should be a level 4 E and M visit. But if the physician is worried that it will get rejected by an insurance company, the physician may code it as a level 3. Level 3 visits do not reimburse as well as level 4 visits. Additionally if there is an audit they may be subject to fines for undercoding. 

LUGPA: What does prior authorization mean? Why is this important?

MARC GREENSTEIN: Prior authorization is when an insurance company tries to determine if a surgery, test or medication is appropriately being ordered by a physician. Prior authorization will hopefully be ruled inappropriate by the government very soon. It is important to know about prior authorization because most insurance companies do not want to approve many surgeries, tests or medications right away. Many insurances follow a step therapy model. In other words, order an ultrasound before you get a CT scan. Get a CT scan before you order an MRI. Or order a generic medication before ordering a branded medication.  If an 85-year-old patient comes in with an overactive bladder, a urologist's first instinct may be to order Myrbetriq or Gemtesa because of the lower side effect profile. However insurance companies would rather you start an anticholinergic because of the cost savings even though the side effect profile is much worse. The Myrbetriq or the Gemtesa will require prior authorization by many insurance carriers.

LUGPA: What is a CLIA number? Why is it important for billing? What happens if it’s invalid?

MARC GREENSTEIN: Clinical laboratory improvement amendments. This is a certification through Medicare and Medicaid for laboratory billing.  I am actually not certain of the ramifications if it is invalid. I do know that it is a regulated certification.

LUGPA: Can we talk about billing liability – who does that fall on?

MARC GREENSTEIN: Everything falls on the physician and the practice. If a physician bills improperly and gets audited, the physician and the practice he or she belongs to would be held responsible.

LUGPA: How does policy in DC affect billing and coding? Can you give examples?

MARC GREENSTEIN: Policy in D.C. Is where billing and coding starts. CMS makes the codes and sets the reimbursement for those codes. They also set the relative value units. Once they make adjustments, the private carriers tend to follow. Transurethral resection CPT code is 52601. Let’s say for 5 years Medicare sets the reimbursement for 52601 for $750. For 5 years the private carriers would follow with similar reimbursement. But let us say CMS reduces the reimbursement for 52601 to $500. I would expect to see the private carriers reduce their reimbursement within a few months based on a change in CMS.

LUGPA: How long did it take you to feel like you understood billing?

MARC GREENSTEIN: I would say at least 2-3 years. I was comfortable with billing for many years and then the rules changed with the new E & M policy. That took me at least 6 months to understand. Our practice uses computer technology to help with our coding. It helps formulate our codes for us by calculating level of care, tests that are being ordered, surgeries that are being recommended. I also used to memorize the old common ICD 9 codes. That changed when they instituted the more complicated ICD 10 codes.

LUGPA: What is a change you want to see across the industry with billing and reimbursement?

MARC GREENSTEIN: I would love to see an end to prior authorizations. I would love to see insurance companies honor modifiers. Many years ago I was once told by a Blue Cross Blue Shield agent that they did not recognize the 25 modifier. So basically they were disregarding the CMS rule of a modifier. I would love to see respectable reimbursement for the care we provide for patients.