Urology: Complex Billing & Coding Requirements

For healthcare providers, medical billing is one of the most complex, tedious backend processes for their nonclinical teams. The nuances and complexities involved in billing vary across different specialties, each specialty comes with its own set of unique obstacles and challenges. Urology, for example, has complex coding requirements that involve modifiers, evaluation, and management codes. These requirements increase room for error and can ultimately result in denials.

In this blog, we’ll dive into the complexities of medical billing and coding in urology.

Coding Complexities

In urology, the complexities associated with medical billing and coding stem from the nuanced requirements placed upon revenue cycle teams. Urologists perform many different types of procedures, and the range of procedures, services, and care provided result in a need for detailed documentation and meticulous coding. These procedures can range from diagnostic testing, to cystoscopies, robotic surgeries, and more.

To maximize reimbursement, revenue cycle teams in urology must consider multiple modifiers and ensure they are using accurate CPT codes.

Modifiers can indicate information about:

• The medical equipment being used
• If procedures are performed on the same side
• If a procedure was discontinued
• Decisions for surgery
• And so much more

If any modifiers are used incorrectly or the wrong CPT code is recorded, it will result in a denial.

Evaluation and Management Codes

In addition to CPT codes and modifiers, revenue cycle teams in Urology must be cognizant of E/M codes. E/M stands for Evaluation and Management codes, and are used for billing of services like consultations, hospital admittance, or physician and nonphysician practitioner clinic visits.

These codes differ from procedure codes, which are used when an action is taken in that they are used during evaluation of a patient. A good example of this is when a patient comes in to inquire about a procedure. The patient may come into the office, speak with a doctor about a procedure they’re looking to have done, and make the appointment for the procedure or surgery. That visit would be billed via an E/M code, and the follow up visit for the procedure would be billed via a procedure code. Modifiers can be added to E/M codes to provide further information about severity of diagnosis and the full evaluation of the patient. Ensuring the proper codes are used the first time around is the fast track to driving reimbursements in urology.

Technology that Makes Complex Billing Simple

Adonis Intelligence can help revenue cycle teams in Urology drive maximum reimbursements. Here’s how:

1. Intelligence can track payer-specific requirements, such as the use of multiple modifiers across a wide range of diagnostic and surgical procedures, to ensure that all patient services are accurately reimbursed.
2. By analyzing historical data, Intelligence can predict which claims are most likely to be denied based on patterns in payer behavior and claim data and recommend corrective actions before the claim is submitted.
3. Intelligence guides RCM teams in navigating complex bundling rules to ensure they receive accurate reimbursement for the services provided.

Adonis Intelligence helps teams submit claims faster and more accurately, detects patterns and trends that can cause denials, and offers corrective courses of action so that teams can recover the revenue they are owed.