Urology Coding Alert

Take pressure off your bottom line with these tips

Urodynamics diagnosis and procedure codes don't have to be uncharted waters if you're following this rule of thumb: Urodynamics tests are diagnostic procedures, not part of a routine examination.
 
Typically, urodynamics sessions consist of uroflow (51741 or 51736), cystometrogram (CMG) (51725 or 51726), and leakpoint pressure (LPP) tests (51795), mainly for diagnosing intrinsic sphincter deficiency (599.82), says Morgan Hause, CCS, CCS-P, coding specialist with Urology of Indiana in Indianapolis.
 
Many private payers try to bundle 51795 into 51726 because they are performed at the same session. You can support separate billing if you have separate reports at each machine, he says.
 
"We do LPP and complex CMG before sacral nerve stimulation because we want to know how the patient might benefit from a nerve stimulator," Hause says.    Interestingly, a simple CMG pays more ($328.49) than a complex ($324.81), according to the Physician's Fee Schedule, because a simple CMG requires the provider to be present throughout the test.
 
The interpreting physician should code urodynamics procedures based on the resulting diagnosis. If the test result is normal, use the patient's complaint. For example, if the test reveals intrinsic sphincter deficiency (ISD), use ICD-9 599.82, but if the patient's complaint is not ISD, use stress incontinence (625.6) as the diagnosis. 
 
Although ISD and stress incontinence are the most common diagnoses in urodynamics testing, carriers with local medical review policies for these codes have long lists of payable diagnoses, some including new additions as of last fall: 598.9 (Urethral stricture, unspecified), 600.00 (Hypertrophy [benign] of prostate without urinary obstruction) and 600.91 (Hyperplasia of prostate, unspecified, with urinary obstruction).

Urodynamics Tests Are Not for Routine Screening

Do not bill any of the urodynamics codes unless there is a sign or symptom of voiding dysfunction. You may not use urodynamics procedures for screening or routine exams.
 
Voiding pressure studies (51795 and 51797) evaluate different functions. Code CPT 51795 refers to the measurement of the ability of the detrusor muscle to contract, and can detect outlet pressure obstruction. Urologists often perform 51795 with 51726 to diagnose obstruction.
 
Code 51797 refers to a procedure to compare intra-abdominal pressure to detrusor muscle function.
 
The cystometrogram (51725) indicates if the detrusor muscle is functioning properly - it detects the capacity of the bladder and abnormal detrusor sphincter contractions.

If the patient's incontinence is due to stress, the cystometrogram is normal. Use 51726 when you have calibrated electronic equipment that performs simultaneous measurements of intra-abdominal, total bladder and true detrusor pressures.
 
Urologists usually use uroflowmetry procedures (51741, 51736) to measure decreased flow. Decreased flow indicates a malfunctioning detrusor due to obstructing benign prostatic hypertrophy (600.01), a cystocele (618.x, 596.8), neurologic lesions, or other reasons. Increased flow indicates a malfunctioning urethra, which can lead to stress incontinence or intrinsic sphincter dysfunction.
 
Code urethral pressure studies (51772, Urethral pressure profile studies [UPP] [urethral closure pressure profile], any technique) only in the case of an artificial urinary sphincter.   Carriers do not cover these rarely performed tests unless other tests are inconclusive. Use these tests to rule out severe urethral incompetence. Urologists use these tests to evaluate suspected cauda equina syndrome.
 
Another diagnostic tool is stimulus-evoked response (51792, Stimulus evoked response [e.g., measurement of bulbocavernosus reflex latency time]).
 
In this procedure, urologists apply electric stimulation to the clitoris or glans penis. Delayed or lack of response to the stimulation may indicate a neurologic lesion.

Use Modifier -26 Outside the Office

Append modifier -26 (Professional component) to all urodynamics codes when performed in a hospital or any other facility outside of the office, such as a nursing home, and receive payment for only the professional component.
 
If you own the equipment and bring it to a hospital or nursing home, continue to code all components with modifier -26. The facility should bill for the technical component, and the urologist should seek compensation for use of his equipment from the facility.
 
The urologist should negotiate reimbursement with the hospital or nursing home.
 
According to CPT guidelines, "When the physician interprets the results and/or operates the equipment, a professional component, modifier -26, should be used to identify physicians' services."
 
"I guess the key is 'and/or' for interpretation and the procedure itself," says Dan Rogers, practice administrator for Gulf South Urology in Biloxi, Miss. "Of course, this only applies when the equipment is not owned by the physician."
 
When the urologist performs urodynamics services in the office, "you don't add the -26 modifier if you do the test and interpret the results AND own the equipment," says Rosemary Russell, AAPC, CPC, of Maine Urology Associates in Bangor.

Report Each Component for Full Reimbursement

Adding video equipment to urodynamics studies further complicates your coding.
 
When you add the video component to urodynamics studies, report the codes that reflect the contrast agent injection, the reading of the video films and fluoroscopy where applicable, as well as the urodynamic components.
 
Medicare and most private and third-party payers will pay for each individual component that the physician performs and documents if the procedure codes and corresponding diagnosis codes prove medical necessity for the procedure.
 
When you report multiple urodynamics codes for a single patient encounter, list the most expensive (that is, highest reimbursed) code first, followed by the other CPT codes, each with modifier -51 (Multiple procedures) - only when submitting claims to non-Medicare carriers.    Medicare personnel prefer to append modifier -51 by themselves.
 
If your urology group uses video equipment made available by a hospital, you must append modifier -26 to the radiology codes 74455 or 76000 to indicate that you only provided the professional component, or reading of the video.
 
Be sure your physician includes extensive radiology reports before submitting a claim for radiology
interpretations.
 
When you perform urodynamics studies without video equipment, you can typically expect to receive full payment (80 percent of the allowed amount) for the most expensive procedure performed - in Medicare's case, the most expensive urodynamics code for 2004 is 51726.    

Medicare will pay 100 percent (of the 80 percent of the allowed amount) for this code and 50 percent of (the 80 percent of the allowed amount for) the fee for all other components reported.
 
According to CPT guidelines, a physician must supervise all urodynamics procedures.
 
The urodynamics codes also imply that the physician supplies all instruments, equipment, fluids, gases, probes, catheters, technician's fees, medications, gloves, trays, tubing and other sterile supplies. Otherwise you must append modifier -26 to the code, for example, when the procedure is done at a hospital outpatient department and the supplies are not the physician's.
 
If you performed the video portion of the urodynamic studies in a facility or hospital setting and it was  interpreted by a radiologist who is employed by that facility or a radiology office, you cannot charge for your urologist's viewing of the video.
 
But you may be able to use your urologist's reading and viewing of the x-ray study toward the medical decision-making component of an E/M service.