Urology Coding Alert

CPT Codes 2002 added language to the surgical guidelines providing useful information on what is and isn't included in the surgical package. Key changes for urologists include 1) the preoperative period includes the day before and the day of surgery and 2) treatment of complications may be reported within the postoperative period with appropriate modifiers.

The global code always includes the following services:

Anesthesia Is Included in Global

Anesthesia by the surgeon is included and not separately billable from the global code, says Michael A. Ferragamo, MD, FACS, assistant clinical professor of urology at State University of New York, Stony Brook.

For example, a urologist performs a penile block (64450*, Injection, anesthetic agent; other peripheral nerve or branch), with a combination of lidocaine and Marcaine, and a circumcision (54161, Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn) on a 66-year-old male. You should code only the circumcision with 54161. Because the surgical fee includes the infiltration with the local anesthetic, the physician cannot bill or expect payment from the patient. This includes any supervisory role that the surgeon may have with a certified registered nurse anesthesiologist or other professional.

However, a commercial payer will sometimes reimburse the surgeon for anesthesia or conscious sedation (99141, Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) in addition to the procedure. Under these rare circumstances, regional or general anesthesia (not local) provided by the urologist may be reported by appending modifier -47 (Anesthesia by surgeon) to the basic service.

In the circumcision scenario, if anesthesia is provided, code 54161-47. If the urologist provides conscious sedation, report 54161 and 99141. Because 99141 is for the physician performing the procedure, do not use modifier -47.

Note: Per CPT, do not use modifier -47 on the anesthesia codes (00100-01999).

Decision for Surgery

CPT rules for preoperative care now coincide with Medicare rules. According to Medicare, the urologist may bill for related or nonrelated office visits up to the day before surgery, even if the decision for surgery had previously been made. Medicare's processing system does not edit for global visits prior to the day before the major surgery, notes Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding and compliance consultancy in Denver.

Some private payers, however, maintain that once a decision for surgery has been made and documented in the record, the preoperative period begins, even if surgery occurs four to six weeks later. Therefore, they feel there should be no payment for any related care during this time interval. You should inform them that CPT has changed its surgical-package definition.

A consultation and decision for surgery conducted the day before or the day of major surgery is payable with modifier -57 (Decision for surgery). For example, a urologist consults (9925x) for a patient with heavy urinary bleeding secondary to a large kidney cancer. Because of the heavy bleeding, a decision is made to perform a radical nephrectomy (50230, Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy) the next day. Code 50230 has a 90-day global period, including one-day preoperative. Bill the consultation with modifier -57 appended to indicate the decision for surgery the day before. Code day one 9925x-57 and day two 50230.

If an unrelated procedure or service is provided on the day before or day of a major surgery, modifier -24 (Unrelated E/M service by the same physician during a postoperative period) or -79 (Unrelated procedure or service by the same physician during the postoperative period) is required to remove the service(s) from the global package of the major surgery.

For example, a patient is scheduled for a TURP (52601, Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]). The day before surgery, the patient presents with hematuria. The patient is evaluated and a cystoscopy is performed. You should bill 52000 (Cystourethroscopy [separate procedure]) with modifier -79 appended and a diagnosis of hematuria (599.7), Page says. The physician may also report the E/M with modifier -24 if the preoperative exam for the TURP is not performed during the same encounter.

The decision for surgery is part of the preoperative surgical package and does not warrant separate reimbursement from the E/M service. The urologist at the initial examination, consultation, or subsequent visit may make the decision for surgery. For example, following an examination, the urologist decides to perform a radical prostatectomy (55810-55815, 55840-55845). The examination and decision for surgery are accomplished at the same encounter. Report only the E/M service (99201-99205, new patient office visit; 99211-99215, established patient office visit; consultation) for that encounter.

Occasionally a decision for surgery is made at one encounter and the urologist completes the history and physical examination at a second encounter. Strict CPT interpretation now allows payment for both encounters as long as the second visit does not occur on the day before or the day of surgery.

Preoperative Exams

To bill for preoperative exams, you must prove medical necessity. Consider V72.81-V72.85 (Special investigations and examinations; other specified examinations) as the primary diagnosis when appropriate. Medicare has instructed its carriers not to routinely deny the above ICD-9 codes but to consider medical necessity.

In addition to the V72.8x codes, also report the secondary diagnosis codes for the condition that prompted surgery and/or the conditions that prompted the preoperative examination, Page says. Some carriers state that if only the V72.8x code is reported, the claim will be denied for medical necessity. "Separate billing for preoperative exams will most commonly allow payment to the physician who has been requested by the surgeon to clear the patient for surgery," Page says. "For example, if a patient is scheduled for a TURP but has a heart condition, so is sent to a cardiologist for clearance, Medicare will reimburse the cardiologist." All routine preoperative exams are included in the global.

For example, a urologist sees a patient and, that day, recommends a radical prostatectomy. The patient says, "I'll think about it." The next day, the patient calls and agrees to surgery, which is scheduled for six weeks later. The physician says to come in for a complete examination first. Some practices perform the preoperative examination two or more days before the procedure, which, for Medicare, puts it outside the global and makes it a payable service. CPT now confirms that this timing places the preoperative exam outside the global surgical package.

Postoperative Care

Postprocedure work includes instructions to the patient or family regarding the postoperative wound care, complications to look for, completion of medical records, any communication to the referring physician, and anesthesia recovery time, Page says.

Immediate postoperative care is included in the surgical package and should not be billed separately. Routine or special care in postanesthesia recovery such as irrigation of catheters, changing dressings, inserting nasogastric tubes, or restarting intravenous therapy is also included in the surgical package. In addition, postoperative care discussions with the family are included.

"Typical" postoperative follow-up care is also included in the CPT surgical package. For example, a urologist performs a TURP (52601), which has a 90-day global period, and the patient has a normal recovery. The urologist sees the patient several days in the hospital and for follow-up office visits. You should not bill for any of this routine postoperative care during the 90-day global period.

Treatment of atypical events such as complications is separately billable with appropriate modifiers, according to the CPT definition; Medicare says, however, it must be performed in the OR, in which case modifier -78 (Return to the operating room for a related procedure during the postoperative period) should be appended to the procedure code.

For example, following a TURP, the patient bleeds heavily on postoperative day three, requiring a return to the OR for cystoscopy and evacuation of obstructing clots. In this case, Medicare will pay for 52001 (Cystourethroscopy with irrigation and evacuation of clots) with modifier -78 appended, indicating treatment of a complication in the OR.

Many commercial carriers and HMOs will pay for the treatment of complications in and out of the OR with modifier -24 appended to the E/M service and modifier -79 to the surgical service. A different diagnosis from the surgical diagnosis is required.