Claims Processing Software Shorts Physicians on Payments

Fix the software. That was the Academy's message to two health insurance payers that have raised the ire of some family physicians who aren't getting paid for urinalysis testing for patients when the test is performed during an evaluation and management visit.

Letters recently went out to Mark MacDougal, vice president of TRICARE Claims Services, and Chris Jagmin, M.D., Aetna's medical director for policy and administration, asking them, and all other payers, to "respect the care provided by family physicians and pay them for performing a urinalysis on the same day as an office visit … and update your claim logic software accordingly."

According to the letters, Aetna's McKesson Clear Claim Connection^TM software and TRICARE's ClaimCheck® system both bundle payment for CPT code 81003 with an E/M service when provided on the same day.

Calling it "inappropriate" for payers such as TRICARE and Aetna to bundle a urinalysis as "incidental" (similar to giving a patient an adhesive bandage) to an office visit, AAFP Board Chair Mary Frank, M.D., of Mill Valley, Calif., gave concrete reasons for the Academy's stance.

First and foremost, "dip urinalysis is important to good patient care," and it is routinely used to check for protein or albumen during pregnancy and in patients with diabetes, said Frank. It's also a useful tool in deciding on an appropriate treatment for a urinary tract infection.

In addition, said Frank, the bundling of urinalysis with E/M services is contrary to CPT instructions. "CPT directs physicians to report urinalysis separately from E/M services when both are provided to the same patient on the same date."

Bundling payment of the urinalysis with the office visit disregards the fact that the urinalysis represents a physician practice expense, said Frank. The total estimated cost to the physician for the urinalysis strip test is $4.65 -- $4.16 for labor and $0.49 for supplies -- continued Frank, and that estimate doesn't include the indirect expenses the practice must apportion over all services provided.

Frank compared two diagnostic tests to make her point. "The urinalysis process is similar to venipuncture preparation for which there is a separate billable code," she said. "Urinalysis is an expense separate from the E/M service that is not included in the valuation of E/M services. … This is why Medicare and other payers -- who appropriately use the resource based relative value scale -- pay urinalysis separately from E/M services."