Urology Coding Alert

Automatically appending modifier 52 could be costing you hundreds.

When your urologist works with another physician during a procedure, you may face major coding challenges. If you don’t coordinate your coding with the other physician’s coder, both doctors could lose money and face audits.

Learn how to correctly code for these shared procedures with this real-world case study.

Review the Surgical Case

Scenario: A urologist and a general surgeon performed surgery on a patient. The urologist did an orchiopexy and performed the opening and closing. The general surgeon performed an inguinal hernia repair.

Coding dilemma: Betsie Ortiz, CPC, professional fee coordinator and charge capture surgery team lead at University of Washington Physicians urology department in Seattle, who presented this case study, wonders which codes each physician should report, and which modifiers coders should append.

No Bundle Means 2 Codes

CPT and the Correct Coding Initiative (CCI) do not bundle these two procedures. In fact, if your urologist performed both the hernia repair and the orchiopexy without another physician, you would report both procedure codes.

For this case study, however, each physician will report his portion of the procedure. The general surgeon will report the appropriate inguinal hernia repair code -- such as 49500 (Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible) or 49505 (Repair initial inguinal hernia, age 5 years or older; reducible). The urologist’s coder will report the applicable orchiopexy code (54640, Orchiopexy, inguinal approach, with or without hernia repair).

Expert Opinions Diverge on Modifier 52

When it comes to deciding whether to attach modifier 52 (Reduced services) to the hernia repair when the urologist, rather than the general surgeon, performed the opening, you’ll need to confer with the physicians and review their documentation.

Some experts say that the opening and closing are very small parts of the total procedure and should not require you to append modifier 52, because any reduction in reimbursement from using modifier 52 would overvalue the amount of time and effort devoted to the opening/ closing. Some coders, however, feel that reporting the code without a modifier is not correct coding.

"I personally don’t add the 52 modifier because the opening and closing for this type of procedure usually represents a minor portion of the total procedure, and I don’t feel that the global fee should be reduced based on this," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Stony Brook. "With modifier 52 the insurance carrier will often reduce the global fee by one-third or more, much too much for just the opening and closing of a wound."

"We have had several cases lately with other surgeons and I have never thought to append modifier 52 because we didn’t open and/or close," says Karla D. Garcia, CPC, coder for Dr. West and Dr. Mayo in Paducah, Ky.

Alternative: Some coders disagree, and say that when a physician uses the same incision as another surgeon for his particular operative procedure, he should use modifier 52, indicating that he did not perform the opening or the closure of the incision.

"If your surgeon did not open or close the patient you would report your coding with a modifier 52," says Betsy Donnelly, CPC, PCS, multi-specialty coder at Martin Memorial Health Systems in Stuart, Fla.

Bottom line: You should use your best judgment based on the operative report and the rules your payer sets up for modifier 52.

Pitfall: Don’t append modifier 53 (Discontinued procedure) because your urologist didn’t open or close. Use modifier 52 when the physician completed what he or she set out to do, but did so performing less than the complete procedure.

Use modifier 52, not 53, when the physician completed the surgery, but to a lesser extent than the code describes, Garcia says. "For me, the key phrase is ‘accomplished some result.’"

"An incomplete or cancelled procedure would use modifier 53, not modifier 52," agrees Laureen Jandroep, OTR, CPC, CPC-H, CPCEMS, coding analyst for CodeRyte, Inc. and senior instructor for codingcertification.org. (See the shaded box on the next page for more on modifier 52 versus modifier 53.)

Prepare to submit documentation: When submitting a claim for a procedure with modifier 52 appended, bill the procedure at the full global fee and prepare a detailed operative report and covering letter that explains what wasn’t done and why.

"Don’t reduce your fee or else the payer may reduce your reduction," Jandroep cautions. "Modifier 52 is one of those modifiers that will require documentation due to the varied circumstances. It is not a modifier that triggers a mathematical formula to be applied."

Skip Modifier 62

You should not use modifier 62 (Two surgeons) or modifier 80 (Assistant surgeon) in this case study.

You would only report co-surgeons (using modifier 62) if the surgeons worked together on the same procedure, each performing a portion of the total procedure, and both report the same CPT code, Ferragamo explains. In this case, each physician would document, in separate operative reports, the part or portion of the total procedure he performed.

Example: Two urologists perform a radical cystectomy with a continent urinary reservoir during which one surgeon performs the removal of the bladder and the other does the continent urinary diversion. You would report the procedures each surgeon performed using the same procedure code for each surgeon (51596, Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder). Append modifier 62 to the surgical code, indicating that one urologist did the cystectomy and the other the urinary diversion.

But modifier 80 may not be appropriate for the case study Ortiz presented. Technically, the surgeons are not assisting one another. Assisting usually occurs when the surgeons are both working together on a procedure (or procedures). (See the shaded box below for more on modifier 62 versus modifier 80.)

How it works: "If the surgeon is working on the hernia while the urologist is working on the orchiopexy, they are not assisting each other," Garcia explains. "They are not sharing equal work and responsibility for one procedure. Since they are both performing their own distinct procedure, you would bill your surgery alone, with no modifier."

Alternately: Many non-Medicare carriers will reimburse for assistant surgeon charges when two surgeons performing separate procedures at the same operative encounter also assist each other. Append modifier 80 to the surgical code (as long as the surgical codes do allow for an assistant surgeon). For the original example that Ortiz presented, note the following coding:

Urologist:

• 54640 for the orchiopexy

• 49505-80 for the surgical assistant (payment for an assistant for 49505 is allowed without specific documentation)

General surgeon:

• 49505 for the hernia repair

• 54640-80 for the surgical assistant (payers re-quire documentation specifying the necessity for an assistant)