Urology Coding Alert

Coordinate coding with the other physician or prepare for a slew of denials

When your urologist and another physician co-manage a patient's case, you may be tempted to automatically apply modifier 54 or 55, depending on your physician's work. If you're not careful, however, you could be raising a red flag with Medicare and your other payers.

Key points: Make sure you append a co-management modifier only when both physicians share the patient's care, and ensure that you're performing the co-management service for the patient's benefit, not for the practice's financial benefit. Your physician needs to document the reason for this approach to providing shared care in the medical record prior to the surgery, as well as the patient's request for, understanding of, and agreement to this care plan.

Make Sure 54 and 55 Go Hand-in-Hand

You should append modifier 54 (Surgical care only) to the procedure code when the surgeon provided only the surgical portion of a CPT code, says Regan Bode, CPC, CPC-EM, ACS-EM, OCS, product manager for Custom Coding Books in Seattle. When you attach modifier 54, you're telling your carrier that the urologist performed the surgical procedure but not the postoperative services.

Note: Medicare includes the service's preoperative reimbursement in the payment to the physician who performed the surgery. Medicare does not recognize modifier 56 (Preoperative management only), says Maggie M. Mac, CMM, CPC, CMSCS, CCP, ICCE, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla.

If your urologist is performing only a procedure's postoperative care, you should append modifier 55 (Postoperative management only) to the procedure code.

How it works: "Most surgical CPT codes are broken down into a 10/70/20 split," Bode says "This means, of the total allowable for the CPT code, 10 percent is allocated for preoperative work, 70 percent for the surgical portion and 20 percent for postoperative work." (Note that these percentages are only averages, and CPT code inter-service values may vary.)

Example: A rural urologist sends his patient to an academic institution in the city and to an oncological urologist for an open radical retropubic prostatectomy with nodes. Following surgery, the oncological urologist returns the patient to his local urologist for postop care. The academic urologist should report the surgical code (55845) and attach modifier 54. The rural urologist will report the same procedure code and append modifier 55 with the date of his care the same as the date of the surgery.

Remember: You must ensure both physicians' offices coordinate postoperative care and enter the number of postop care days each sees the patient and submit them on separate claim forms, Mac says. Often, the oncological urologist will want to see the patient for at least the initial postoperative days before releasing further care to the rural-based urologist.

Caution: If you're reporting the postoperative care using modifier 55, make sure the surgeon who performed the procedure reported the service with modifier 54. Otherwise the carrier will deny your claim because it has already reimbursed the surgeon for providing the full care associated with the code. As often happens, this is too difficult to coordinate, and the rural urologist may choose to report an appropriate E/M code whenever he sees the patient rather than using modifier 55 for the follow-up care.