Urology Coding Alert

HCFA temporarily suspended many of the edits in Version 6.3 of the national Correct Coding Initiative (CCI). These edits had bundled more than 800 procedural codes with evaluation and management (E/M) codes, taking the coding world by surprise when they were issued last fall (see Urology Coding Alert November 2000, page 81). The suspension is retroactive to Oct. 30, the date the 6.3 edits were issued.

The bundling of the E/M codes with diagnostic and radiological procedures required urology coders to use modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) when the E/M service represented a separate and significant service. HCFA now wants to educate the physician and coding community as to what a separate and significant service really is, says Linda S. Dietz, ART, CCS, CCS-P, coding specialist with CCI Edits. They want to do some education on how to use the -25 modifier, Dietz says.

The suspension of the edits does not mean urologists can add 99211-25 (established patient) each time they perform a scan. If you have submitted claims that were rejected due to the edits, you should look at these claims and see if modifier -25 applies, Dietz says. If it does, then resubmit the claims, she says. If it doesnt, then we would not expect that claim to be resubmitted. Correct coding dictates that you cannot bill for a service that was not performed. Modifier -25, when appended to an E/M code, is defined as representing a service that is significant and separately identifiable from another service or procedure. The edits have been temporarily suspended, but that doesnt mean we dont expect correct coding, Dietz says.

An example of when an E/M service with modifier -25 appended would be justified when performed on the same date as one of the procedures in the 6.3 edits is the collagen skin test, says Morgan Hause, CCS, CCS-P, coding compliance specialist with Urology of Indiana, a 17-urologist practice in Indianapolis. The procedure (95028, intracutaneous [intradermal] tests with allergenic extracts, delayed type reaction, including reading, specify number of tests) is performed to determine whether a patient is sensitive to collagen prior to performing an implant procedure for intrinsic sphincter dysfunction. The scenario under which you could bill for an E/M in addition to 95028 is this: the urologist, who has already seen the patient for the sphincter problem at an earlier visit, explains the collagen implant treatment. The urologist also discusses the sensitivity test that will have to be performed first. The E/M code would probably be an established patient visit (99212-99215), and the level would be based on time because more than 50 percent of the visit would be consumed by counseling. Append modifier -25 to the E/M visit, and bill it with 95028.

It is not permissible and was not permissible even before the 6.3 edits took place to bill 99211 with 95028 when the patient comes in at a different date for the collagen sensitivity test. Whenever you use 99211, you have to ask yourself, Am I double-dipping? Hause says.

The temporary suspension means only that HCFA is giving you a chance to look at your claims again. Before using modifier -25, make sure the service is significant and separately identifiable from the procedure.

HCFA is reviewing the edits and may re-implement many of them as early as July 1, 2001.