Urology Coding Alert

There are some similarities among LMRPs, notably coverage of the injection procedure. The injection of the corpora cavernosa to produce an erection (54235) is usually performed by the patient at home and is not billable. In the office, you should report 54235 only once to assess the patient's reaction to the drugs, and/or to titrate the proper dosage. The medications are payable once with J0270 (Injection, alprostadil), J2440 (Injection, papaverine HCl), J2760 (Injection, phentolamine mesylate [Regitine]) or J3490 (Unclassified drugs). When the patient returns for a visit, perhaps to learn how to inject himself, and the nurse teaches him, you should code 99211 (established patient, office visit ... that may not require the presence of a physician) only.

"Whether the doctor can bill for a separate E/M in addition to the injection depends on the purpose of the visit," says Joan Gilhooly, CPC, CHCC, of Medical Business Resources, a coding consultancy in Deer Park, Ill. "If a patient comes in for the sole purpose of having a procedure done, do not bill for an E/M. But if something else is performed, such as an evaluation or assessment for side effects, a separate E/M is justified."

A patient with a complaint of impotence is referred to a urologist. The urologist bills a consultation and recommends that the patient return later in the week for the injection procedure (54235). Do not bill a separate E/M for the injection procedure, unless separate work is done. If, however, the urologist (or nurse) performs the injection procedure the same day as the consultation, bill the procedure (54235) and the consultation (99241-99245).

Noridian, in its LMRP for Colorado, North Dakota, South Dakota and Wyoming, states that if a man consults a physician for inability to maintain an erection, "the diagnosis of impotence can be said to be confirmed." Allowable diagnoses are 302.70 (Psychosexual dysfunction, unspecified), 302.72 and 607.84.

Noridian requires that any E/M service billed on the same day as 54235 be "separately identifiable" and have supporting documentation for this in the record. Noridian says the separate E/M code may be appended with modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

Noridian rarely reimburses for 54250 (nocturnal rigidity testing), recommending instead that the physician question the patient about sleep problems. However, under limited circumstances a lifelong history of erectile dysfunction or an inability to determine whether the condition is organic or psychological Noridian will cover 54250 using a home monitor, which produces a readout that the urologist interprets. Regardless of how many nights the machine is used, only one unit of 54250 may be reported.

Vascular testing (93975-93981), with possible penile revascularization (37788), may be covered for men under 45 years old, with a history of perineal or pelvic trauma, who have arterial blockage. "Coverage for any of these procedures will be rare," the LMRP cautions.

The carrier never covers penile plethysmography (54240) and noninvasive vascular studies (93922-93971).

Do not perform these tests and bill an E/M code instead of the test code. If a code exists for a service or procedure performed, that code must be used. It is fraudulent to roll services into another code, especially for payment purposes.

For any tests that the carrier views as medically unnecessary, if the patient agrees to pay the urologist directly, first obtain an advance beneficiary notice.