Urology billing and accounts receivable

In-office procedures, drug administration and global periods create a dense mix of professional and supply billing.

Where the money leaks in urology

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• In-office procedure denied for place-of-service mismatch
• Drug units miscalculated against the HCPCS descriptor
• Urodynamics components unbundled incorrectly
• Prior authorization missing for advanced imaging
• Global period conflicts after a same-site procedure

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working urology, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-16 — Claim lacks information
  Something on the claim is missing or malformed. On its own the code tells you nothing — the detail is in the remark code that comes with it.
  Recovered by being corrected and resubmitted. Matched from: “Drug units miscalculated against the HCPCS descriptor”
• CO-197 — Prior authorization absent
  The payer required prior authorization for this service and cannot find one attached to the claim.
  Recovered by being taken back to the authorization. Matched from: “Prior authorization missing for advanced imaging”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a urology AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions