Urology Coding Alert

When a urologist decides to perform surgery immediately after seeing a patient, he or she can get paid for that initial encounter only by appending a modifier. Whether to use modifier -57 (decision for surgery) or modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) often confuses Urology coders . In general and always for Medicare use modifier -25 on all E/M services associated with minor procedures. Use modifier -57 for an E/M service during which you decide to perform surgery either on the same day or the next day.

By using modifiers -57 or -25, the urologist can be reimbursed for an office visit that is connected in some way to a procedure. Under global surgery rules, if you bill an office visit for a patient on a certain date of service that results in a decision to perform surgery, and that surgery is done within 24 hours of the office visit, you cannot be paid for the office visit. Modifiers -25 and -57 make an exception to those rules, enabling you to receive payment.

Many coders think modifier -25 is for minor procedures, and modifier -57 is for major procedures. But Medicare says to use modifier -25 for procedures with a 0- to 10-day global period, and modifier -57 for procedures with a 90-day global period.

However, CPT does not mention global periods. The 90 days or 0 to 10 days requirements are just for Medicare. A blanket statement such as modifier -57 is only for 90-day globals is misleading if billing a private payer, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a Denver-based billing and coding consultancy. It is a Medicare guideline that limits the use of modifier -57 to procedures with 90-day-or-above global periods, Page says. For CPT coding, all codes in the 10040-69979 range, with the exception of starred procedures, are classified as surgeries. Therefore, technically, modifier -57 could be used for charging an E/M service with any of these codes, Page says. The coder must know how individual payers interpret the -25 and -57 modifiers.

For some private payers, you may have to use modifier -57 for either minor or major procedures. Some private payers still refuse to pay a modifier -25 claim in full. Some of these will pay modifier -57, so you should resubmit the claim with it. However, Medicare restricts the use of modifier -57 to major procedures.

Modifier -57 Scenarios

TURP: A patient comes in on a Monday with prostatism, and the urologist performs a transurethral resection of prostate (TURP) on Tuesday, says Cheryl Ellis, office manager for Northland Urological, a three-urologist practice in North Kansas City, Mo. Use 52601 (transurethral resection of prostate, complete) for this procedure. The urologist would not get paid for the initial office visit unless we use modifier -57 because the visit took place within the same 24-hour period as the surgery, she says. But if he does the surgery on Friday, he can still be paid for the office visit, and he doesnt need the modifier -57 on the office visit. Code Mondays encounter 992xx, and Fridays surgery 52601.

ESWL: Extracorporeal shock wave lithotripsy (ESWL, 50590) is perhaps the most common procedure to which modifier -57 is appended. If a patient comes in to the office in extreme pain with a kidney stone, well do surgery the next day, says Roseann Lightbody, CPC, coder for Urology Specialties of the Carolinas, a 12-urologist, two-physician assistant practice in Charlotte, N.C. Sometimes, the patient is seen in the hospital first. In either case, put modifier -57 on the patient visit.

Intraoperative Consultation and Procedure: In another example, a urologist may be called to the operating room by the gynecological service. During extensive pelvic surgery, the ureters have not been visualized, and the urologist is needed for an opinion. The urologist examines the patient intraoperatively and finds a transected ureter. He or she performs a ureteroureterostomy (50760), and charges for the operating room consultation as well with a modifier -57.

Modifier -25 and Diagnosis Codes

If the encounter is for a procedure such as a cystourethroscopy, which has a 0-day global, modifier -57 is not appropriate for Medicare patients. For example, a urologist provides a consultation for a patient with lower urinary tract symptoms, and performs a cystoscopy (52000) for microhematuria. The cystoscopy is performed the same day, therefore modifier -25 is required on the consultation code.

Because modifier -25 requires by definition that the E/M service be significant and separately identifiable from the procedure, some coding experts recommend that you use two different diagnoses. In the case of the urinary tract symptoms and the cystoscopy, use different diagnoses for the consultation and the cystoscopy, says Michael A. Ferragamo, MD, assistant clinical professor of urology at the State University of New York, Stonybrook. Use benign prostatic hyperplasia (BPH), frequency or nocturia, for example, on the consultation, and microhematuria on the cystoscopy. CPT and Medicare allow the same diagnosis on the E/M service and the procedure, but individual carriers and private payers dont always recognize that point.

Under slightly different circumstances, you could bill the E/M service and the procedure with the same diagnosis, Ferragamo explains. For example, a patient presents with gross hematuria. This prompts the urologist to perform an examination and a cystoscopy. Both the E/M service and the cystoscopy should have the same diagnosis: hematuria (599.7).

Still, not all carriers and private payers will allow you to bill the E/M service and procedure code with the same diagnosis. They interpret the separately identifiable descriptor of modifier -25 as requiring a separate diagnosis, even though CPT specifically says the diagnosis does not have to be different.

To get paid using modifier -25 if a payer requires a separate diagnosis, you could use the postoperative diagnosis in this example, the findings of the cystoscopy for the cystoscopy procedure, and the preoperative diagnosis for the E/M visit. A bladder tumor (188.x) or hemorrhagic cystitis (595.9) may be causing the hematuria. You could use those diagnosis codes for the cystoscopy, and hematuria for the consultation.

But the two-diagnosis solution is controversial. Some coding experts say it is inappropriate to code the results of a diagnostic procedure as the reason for the procedure in an outpatient setting. After all, these coders say, if you already know the outcome, why would it be necessary to do the diagnostic procedure? These experts insist on filing both codes with the same diagnosis, and then appealing after a denial.

If the findings are normal, and there is only one diagnosis, you may not be paid for the E/M visit, and may have no grounds for an appeal.

Private Payer Denials

Sometimes, managed care companies deny the initial visit, saying its included in the procedure, Lightbody says. These companies sometimes say this regardless of the time period. We have tried using modifier -57, and weve tried modifier -25, she says. Blue Cross/Blue Shield, in particular, has asserted that the decision for surgery is included in the fee for the surgery itself. Because this contradicts CPT, which established modifier -57 so that the physician can bill for the work involved in assessing the patient and the medical decision-making that precedes surgery, Lightbody sends these rejections back for review with a letter explaining the reason for the initial visit.

How can you handle private payers who refuse to pay for the office visit that precedes surgery? Unfortunately, Page says, managed care companies do not have to adhere strictly to CPT guidelines. If a payer doesnt allow the initial visit prior to surgery, and has published this information in some manner that the physicians have access to (such as manuals, bulletins, newsletters), they are within their right to deny benefits, Page says. Of course, you could sue the payer, and probably win, but your win would only be for that specific claim hardly worth it. Dont sign a contract that bans payment for presurgery office visits.