Urology Coding Alert

Question: We have a new urologist in our practice. One of his established patients from his last practice wants to have surgery before the physician is credentialed with the insurance company. Can we bill for the surgery?


Maine Subscriber


Answer: The answer depends on the carrier. When a patient needs surgery before the physician is credentialed, you can take the private-pay route--if the patient is willing.

Medicare: Medicare will allow you to place your physician's claims on hold from the date he files his Medicare provider number application and then file them once he receives his credentialing. You can do this for all of your urologist's Medicare services while he remains without credentials. Medicare will pay your claims retroactively from the date of the practice's new physician's national provider identifier (NPI) application. You should contact your carrier for details regarding how to do this.

Private payers: Check with the individual payer. Some non-Medicare payers may give you an effective date for when you can start billing.

Remember: You cannot bill services under another provider while you're waiting for the new physician's credentialing completion.

Try this: In the future, you may want to allow your office more time when trying to credential a new physician. The process can take 90 days or even longer, according to Medicare. Experts recommend that you initiate this process as far in advance of your new physician's starting date as you can (once you have all the necessary information such as the state license and drug enforcement administration number)--two to three months ahead of time, if not more.

If you act early, you'll have the necessary credentials in place when the physician starts seeing patients, and you won't have to hassle with delayed payments. Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis.