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UCR 156: How to bill Urocuff in Medicare Advantage Plan; E/M service in global not related to surgery Modifier -24; and urologists billing moderate sedation in hospital

August 4, 2023 

Ray, Mark, and Scott discuss 3 questions that came into the Urology Coding and Reimbursement Group (see below for link to sign up free).

1. Thank you for your recent podcast 147 with attention to updated Urocuff billing.  The recent change from our MAC NGS was helpful as this went into effect June 1, 2023 and they are now recommending billing 55899 as opposed to 51728-52. My question specifically relates to how to bill Medicare Advantage plans.  Do we follow the private payor rules that manage the plan or the MAC recommendation. For example, commercial payor A prefers the urocuff claim submitted as 51728-52.  If the Medicare advantage plan is administered through commercial payor A and we still have to follow their rules regarding prior authorization, utilization of specialty pharmacy for Botox rather than buy/bill for traditional Medicare, etc... It would seem that the urocuff in this case should be billed how we would bill the private payor using 51728-52 vs 55899. Any insight on this would be appreciated.
2. I am new to urology coding and Medicare rules. We have had a couple of patients admitted to the hospital during a surgical global period. These admissions are not related to the surgery. I coded the e/m code with a 24 modifier, but they were denied. Any help would be appreciated on how to get these claims to process.

3.  if our urologists, in the hospital setting, perform a procedure (ex. Ureteroscopy) and also they themselves administer the moderate sedation, are there additional CPT codes they can bill for?  If so, what are those codes?  the cpt book in the anesthesia guidelines seem to indicate that perhaps cpt codes 99151  99152 99153 may be coded to show this?  thank you

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