Urology Coding Alert

Assuming you only need one code might be costing you double-digit amounts.

Your urologist says he performed a "voiding trial," but which set of urodynamics codes should you turn to? With so many urodynamics tests and procedures, you may not even know where to begin. If you don't capture every element of the service the urologist actually performed, your incomplete coding could be costing your practice more than $20 for every voiding trial.

Voiding trials are common practice for urologists. Physicians often have patients come back to the office for a voiding trial to determine if the patient is able to void after catheter removal. Medicare usually will not pay for postoperative voiding trials following procedures such as a prostatectomy (52601, Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) or vaginal surgery (57288, Sling operation for stress incontinence [e.g., fascia or synthetic]), though some private carriers may reimburse you.

However, when a urologist documents that he performed a voiding trial, you will most often be dealing with either a simple bladder irrigation/instillation, a bladder scan, or both. You need to refer to the medical record to see which procedures your physician actually performed.

"51700 is for irrigation or installation," says Kelly Young, a coder with Scottsdale Center for Urology in Scottsdale, Ariz. Therefore, if the urologist documents that he performed a bladder instillation, you should turn to 51700 (Bladder irrigation, simple, lavage and/or installation). In other words, if the urologist is only doing a bladder fill, use 51700 for the bladder fill.

If, however, the urologist documents that he also performed a bladder scan to measure post-voiding residual (PVR) urine, you should also bill 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging). Usually, you will use this code when the urologist positions a portable ultrasound scanner over the suprapubic area to measure the residual urine.

Don't miss: Next year, if your urologist performs both an instillation and the bladder scan, but you only report 51700, you'll be forfeiting $21.64 every time, based on the unadjusted national Medicare Physician Fee Schedule (.60 RVUs times the 2009 conversion factor of $36.0666) for code 51798. For 2008, you were missing out on $20.95 (.55 RVUs times the 2008 conversion factor of $38.0870) every time you overlooked 51798.

Urologists may perform a voiding trial in several ways. You will choose the codes to report based on the pro-cedures your urologist performs during the voiding trial.

"Urologists will sometimes fill the bladder with fluid, have the patient void, then do a PVR, ultrasound residual, code 51798, to make sure the patient is voiding sufficiently to be sent home without a catheter," Young says.

For example: The urologists at Urology Associates Ltd. in Milwaukee, Wis., first perform an instillation (51700), according to billing supervisor Kathy Peters. The physicians fill the bladder, and then ask the patient to void. The urologist measures any residual urine (51798). "This determines whether the catheter needs to be replaced or not," Peters explains.

At Scottsdale Center of Urology, the urologists do things a bit differently, according to Young. "Generally, we will have a patient come in before 9 a.m. and remove their catheter. We have them return to our office around 3 p.m. and do a PVR to make sure they are not going into retention. This helps us avoid 2 a.m. ER calls from patients who might otherwise end up in the ER in urinary retention."

Note: If your office performs voiding trials similar to Scottsdale Center of Urology, make sure you are capturing any E/M services your staff provides in addition to the voiding trial codes. "We bill 99211 when the MA [medical assistant] pulls the catheter in the morning," Young says. If the doctor sees the patient for other reasons or if in the afternoon the PVR is high, then Young bills the appropriate E/M code for the urologist based on the services he provides.