Urology Coding Alert

Winner takes all when submitting claims for interpretation of radiological services. If you want to be reimbursed for your next claim, you'd better be sure it's the first one of its kind to reach the payer.

Many urologist don't realize that they can code and bill for the professional component of radiological services they perform outside the office, such as in a hospital setting - they also overlook some requirements for in-office radiological services, says Michael A. Ferragamo, MD, clinical assistant professor of urology at the State University of New York, Stony Brook. To obtain reimbursement for radiological services, urologists must meet certain criteria.

The key to reimbursement when coding physician interpretation of radiological services in a facility setting is the "professional component" modifier, -26. But to use modifier -26 and earn the additional payment that comes with it, physicians must meet the following criteria, Ferragamo says.

First and foremost, it must be the urologist who does the initial reading and interpretation of the film.

The second requirement of the physician is that she act clinically on the interpretation made from the initial reading. For example, if the urologist reads a retrograde pyelogram and discovers that a patient has a stone, she must then decide to remove the stone, to place a stent or, if the retrograde pyelogram is normal, to terminate the procedure. All of these examples constitute clinical action.

And third, the urologist must write a radiological report similar to that which is required of a radiologist, which is either separate from or a distinct section of the operative report, Ferragamo says. Although in the past carriers required that the radiological report be written on and submitted as an unattached, distinct report, Medicare carriers will now accept the report if it is included in the body of the operative report with some indication, such as a subheading, that it is the radiological interpretation. For example, if the urologist provides a consultation in addition to the professional component of a radiological service, the radiological report can be included in the consultation report, or if in a hospital environment in the progress notes.

Debbie Stephens, CPC, a urology coder in Georgia, cautions coders to watch where they tread when appending modifier -26 to a radiological code. The urologist's reimbursement for his in-hospital service such as a retrograde pyelogram, 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service), includes within the "surgical fee" the injection of contrast agent for which one cannot and should not bill separately. In the past, urologists dictated what was seen on the retrograde pyelogram, i.e., "once the dye was injected no obstruction was noted." This simple description of the pyelogram does not merit a separate fee for the radiology interpretation. A more formal report is needed if the urologist wishes to submit a charge for his interpretation of the films.

Radiologists employed and paid by the hospital historically continue to read all radiological studies, even those for which they were not present or supervised. Unfortunately, carriers will only reimburse for one reading, and if the urologist is paid the professional reading component, the hospital radiology department will only be paid the technical component because it does not own the equipment, Ferragamo says.

In general, CMS will only pay the physician whose radiological interpretation directly contributed to the diagnosis and management of the patient. Most often with retrograde pyelogram this is the urologist, Ferragamo says. He suggests, "Concerning these issues, the urologist may want to confer with the radiologist to avoid any conflict between the services."

According to Stephens, urology practices should be able to bill the professional component of in-hospital services, such as urodynamic studies, when the hospital owns the equipment but the urologist performs the procedure and interprets the tracing, as with 51726-26 (Complex cystometrogram).

If the radiologist interprets the film Monday morning and submits the claim, without knowing that the urologist performed the professional component of the procedure, and the radiologist's claim is the first to reach and be processed by the patient's carrier, the radiologist will be reimbursed for the full amount, destroying any chance of reimbursement for the urologist, Ferragamo says. The moral of the story: Get your professional component claims to the carrier first!

Both Medicare carriers and private insurers typically pay for only one interpretation of the film taken for the radiological service. This not only means that the urologist must be the first to read the film and interpret it but that the urologist also has to be the first to submit the claim to the payer if he is going to be reimbursed. Historically, the radiologist has always charged for the entire radiological service. Therefore, it is critical to follow the three-prong test when your urologist believes he or she is deserving of professional-component reimbursement for a radiological service.

Here is a partial list of radiology services that a urologist may feel entitled to report with modifier -26 under the above circumstances: