Urology Coding Alert

Tip: If the other physician involved is not coding correctly, youre out of luck.

Surgical co-management of a patients problem takes more than just physician coordination. If you and the other surgeons coder are not on the same page, both physicians could lose out on reimbursement. Get your facts straight on when you can apply modifiers 54 (Surgical care only) and 55 (Postoperative management only) with these expert tips.

Look at the Procedure Puzzle Pieces

CPT codes are broken down into a pre-op/surgery/post-op split. This means, of the total allowable for the CPT code, a percentage is allocated for preoperative work,a percentage for the surgical portion, and another portion for postoperative work. If your urologist does not perform all three components, you should not code and bill for the entire (global) fee for a surgical code.

How it works: You should append modifier 54 to a surgical procedure code when your urologist provided only the surgical portion of a CPT code, says Jennifer Vanderhorst, CPC, coder for Michigan Urological Clinic in Grand Rapids. By attaching modifier 54, youre telling your payer that the urologist performed the surgical procedure but not any of the postoperative services.

When your urologist is performing only a procedures postoperative care, you will append modifier 55 (Postoperative management only) to the same procedure code, says Denae M. Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw, Mich.

Tip: You can basically ignore modifier 56 (Preoperative management only) for Medicare claims. Medicare includes the services preoperative reimbursement in the payment to the physician whoperformed the surgery and therefore, does not recognize modifier 56. Many other insurance payers do not recognize modifier 56 either, Merrill adds.

Example: A general urologist in a small town sends his patient to a urological surgeon at a large hospital in a nearby city for a GreenLight laser photoselective vaporization of the prostate (PVP) procedure.

Following surgery, the surgeon returns the patient to his local urologist for postoperative care during the global period. The urologist who performed the surgery should report the surgical code (52648, Laser vaporization of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy,cystourethroscopy, urethral calibration and/or dilation,internal urethrotomy and transurethral resection of prostate are included if performed]) and attach modifier 54. The other urologist will report the same procedure code and append modifier 55 with the date of his care the same as the date of the surgery using the same (surgical) diagnosis.

Where Theres a 55,There Should Be a 54

Communication between your urologist and the other physician(s) involved in the patients treatment is important for proper coding.

Coordination between the surgeon and the provider of the pre/post op care is essential so that all parties involved get appropriate reimbursement, Merrill explains.

If youre reporting the postoperative care using modifier 55, make sure the surgeon who performed the procedure reported his service with modifier 54. Otherwise the payer will deny your claim because it has already reimbursed the surgeon for providing the full care associated with the code. Both physicians should report the same CPT code for the surgical procedure,Vanderhorst stresses.

Shared care related to a surgical procedure is simple in concept but difficult in practice because the surgeon gets less reimbursement and feels forced into sharing the post op, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. If one can keep the focus on the patient and not the rule, things work out.

Alternative: If you are unable to coordinate with the surgeon, you can choose to report an appropriate E/M code whenever your urologist sees the patient for postoperative follow-up care, rather than using modifier 55.