Urology Coding Alert

Facilities will face challenges billing outpatient clinic visits with procedures.

Physician practices are not the only ones affected by Correct Coding Initiative (CCI) updates. If you code for a facility that bills outpatient clinic visits, you need to take note of several edits CCI 20.2 introduces.

Add G0463 Bundles to Your Edit List

CCI 20.2 bundles new HCPCS code G0463 (Hospital outpatient clinic visit for assessment and management of a problem) with every CPT® codes in the urinary system (50010-55920 with the exception of unlisted urinary system  codes) as well as CPT® codes for urogynecology and the integumentary system (skin).

“Code G0463 replaced CPT® codes 99201-99205 (new patient visit) and 99211-99215 (established patient visit) for facility billing of outpatient clinic visits,” says Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M. “This new bundle will not affect physician payment, but will impact a facility that is trying to bill an outpatient clinic visit as well as the service it is bundled into. This bundle just levels the playing field for bundles that apply to physicians and those that apply to outpatient facilities.”

 “Last spring CCI added a bundle of all minor procedures to established E/M codes,” says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “It is not enough for them that the definition of the global period includes a mini E/M, they have to make it even harder and more iron clad that the E/M and the minor procedure are not to be billed together by bundling them, adding an additional level of hurt on top of the global period definition.” 

Don’t Assume Modifier 59 Applies

These bundles all have a modifier indicator of “1.” That means you can bypass the edit with an appropriate modifier if you can meet the criteria for doing so.  

In writing: Per the CCI manual: “A CPT® code with the ‘separate procedure’ designation may be reported with another procedure if it is performed at a separate patient encounter on the same date of service or at the same patient encounter in an anatomically unrelated area often through a separate skin incision, orifice, or surgical approach.”  

Watch out: Often modifier 59 (Distinct procedural service) is the appropriate modifier for unbundling codes that would be deemed separately billable per CCI. However, that is not always the case. 

For example, G0463 would not take a modifier 59 because it represents an E/M service, and the only modifiers that would apply would be modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period), 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service), or 57 (Decision for surgery). 

Tip: “And, by the way, the modifier 25 is not reported for the decision to do a minor procedure; CMS considers the decision to do a minor procedure, part of the surgical code,” Witt warns. “That clinic visit would have to represent a separate and significant E/M service.”