Urology Coding Alert

Documentation is key to getting reimbursed for several procedures in different sites No matter how many coding guides, supplements and resources you collect, there's always a coding dilemma that just won't fit neatly into the scenarios described in CPT Codes or presented in the coding seminar your entire department just attended. See how our experts approach this one-of-a-kind coding conundrum and apply these concepts to your difficult cases.

Scenario: An established patient came to the office after finding blood in his urine. The urologist did a cystourethroscopy in the office and found many dilated vessels, which were the source of the hematuria. The patient also had a greatly enlarged prostate. During the cysto, the patient started bleeding. He stayed in the office for one hour; when the bleeding stopped, the urologist sent the patient home.

The patient returned later that day, complaining of urinary retention. The urologist inserted a Foley catheter and irrigated periodically for three hours, but the bleeding would not stop. He finally sent the patient to the hospital. At the emergency department, the urologist changed the Foley catheter and irrigated for another two and a half hours. The bleeding lessened, and the urologist admitted the patient. The next day, the urologist irrigated again, and a few days later the patient had a retropubic prostatectomy. Modifiers Explain Prolonged Office Visits The bad news: "You will probably never receive all the reimbursement you deserve for the amount of work the urologist did," especially at the hospital, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook. "Many carriers, including Medicare, will want to incorporate all the work you did on that day into a single hospital admission code. Based on that alone, you can never really receive compensation for the hours of work that transpired on that day."

The good news: The right series of codes and modifiers, along with documentation, will go a long way toward explaining the scenario to the carrier.

First: Depending on the level of E/M care your urologist provided, use a code from the CPT 99212-CPT 99215 series (Office or other outpatient visit ... established patient). Append  modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the E/M service was in addition to the cystourethroscopy the urologist also performed at the encounter.

Next: Use 52000 (Cystourethroscopy [separate procedure]) for the cystourethroscopy the urologist performed in the office. And since the urologist spent three hours irrigating the patient when he came back later in the day, you need to report one initial hour, plus four units of 30 minutes apiece. [...]