Urology Coding Alert

Key: Use 1 E/M code for office visit and initial hospital care on the same day

Coding for the removal of a retained catheter is difficult enough on its own. But what happens when the office visit also includes bladder irrigation and clot removal, and is followed by a hospital admission - just a few weeks after the patient has had ESWL?
 
That's the situation Debbie Price, RHIT, at Cullman Urology in Cullman, Ala., faced. Luckily, there are sometimes simple answers for the most complicated questions. Read on to discover Price's solution for this coding problem.
 
The scenario: A patient arrived at the urologist's office with a retained Foley catheter balloon, irrigation port cut off. The urologist was unable to get the catheter out with a flexible guidewire. He also irrigated the bladder, removing several old clots.
 
The patient then went to the ultrasound suite for a transrectal ultrasound. Using a prostate needle biopsy gun, the urologist was finally able to pop the catheter balloon under ultrasound guidance.
 
The urologist spent more than two hours with the patient in the office before admitting the patient to the hospital for IV fluids and antibiotics. The patient had extracorporeal shock wave lithotripsy (ESWL) four weeks ago by another doctor in another town.
 
The dilemma: Price had to decide between using an E/M code for the office time and combining everything into a hospital admission code, she says. She also had to find a procedure code for the balloon catheter removal - "there's not really a CPT code for that," she says.
 
Coding solution: No matter what means the doctor used to remove the Foley catheter, report 51703 (Insertion of temporary indwelling bladder catheter; complicated [e.g., altered anatomy, fractured catheter/balloon]) for the removal, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook. "Code 51703 is also used for difficult catheter removal with or without the reinsertion of a catheter," he says. "This would include the use of a needle to break the balloon."
 
Report 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for the ultrasonic guidance used. Although the National Correct Coding Initiative bundles 76942 into bladder surgery codes 51705 (Change of cystostomy tube; simple) and 51710 (... complicated), the ultrasound guidance is not considered a component of 51703.
 
The next step: What about the office visit and the hospital admission? Your coding depends on whether the urologist saw the patient in the hospital on the admission date, Ferragamo says. When a urologist admits a patient to the hospital from the office but doesn't see the patient in the hospital that day, report only the appropriate-level office visit code (99201-99215). Because the physician doesn't see the patient in the hospital on the admission date, you should use the E/M code that reflects where the physician delivered the services.
 
In this case, the visit occurred in the office, and because the physician performed an office visit only and did not see the patient that day in the hospital, you should only report that day's office visit and service, Ferragamo says. If he were to see the patient the next day in the hospital, you would bill an initial hospital visit, 99221-99223, for that day. "In addition, the urologist would not be bound within the 90-day global of the previously performed ESWL, as he apparently is not associated with the doctor in the other town," Ferragamo says.
 
Key: But when the office visit and initial hospital care occur on the same day, you should roll both services into one E/M code, Ferragamo says. If the urologist also saw the patient in the hospital after the patient was admitted on the same day as the office visit, combine the office visit and initial inpatient hospital care into one hospital E/M code (99221-99223). Because the initial hospital care's date coincides with the admission date, you should consider all related E/M services that the physician provides on that day as part of the initial hospital care and submit only the initial hospital care codes.