Ob-Gyn Coding Alert

Question: In January, a patient came into the office for a tension-free transvaginal tape (TVT) procedure for female stress incontinence. She returned roughly a month later for suprapubic catheter placement for urinary retention. I billed the catheter placement with 51010. Should I attach modifier -58 to the code as well?

Kentucky Subscriber

Answer: No, you should not attach modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to 51010 (Aspiration of bladder; with insertion of suprapubic catheter) in this situation. The ob-gyn placed the catheter because of a complication of the TVT procedure, and the physician likely did not plan this in advance. In addition, the catheter placement is not a more extensive procedure than the TVT, and it is not therapy following a diagnostic procedure.

Similarly, you would not use modifier -78 (Return to the operating room for a related procedure during the postoperative period) because the patient did not go back to the operating room.

If the surgeon planned the subsequent catheter placement when he performed the TVT, you would append 51010 with modifier -58. Consequently, unless the ob-gyn planned the second procedure, you should report 51010 with no modifier. But you should send a letter to the carrier explaining the situation just in case the payer wants to include the 51010 in the global period for the TVT procedure.