Urology Coding Alert

Don't forget to append modifier 25 when you report multiple services

When your urologist performs a procedure such as a transurethral resection of the prostate (TURP), you should closely review the documentation for indications of a separately identifiable E/M service, or you may be missing out on an opportunity to report both the procedure and a separate E/M service. The following expert advice will help you determine whether the service your physician pre- or postoperatively provided constitutes an additional E/M.

Documentation Must Support Separate Billing

If you have a hard time determining what constitutes a separate E/M service when your urologist performs a procedure, remember that your physician needs to document a significant, separately identifiable service.
 
For every procedure your physician performs, he must complete a cursory history and physical (H&P) on the day of the procedure, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. So, to report a separate E/M service, your urologist must document a service that is above and beyond the pre- and postoperative care associated with the procedure.

u can't report a separate E/M for information that your urologist gathers for the H&P required by the hospital. This is usually an administrative H&P examination required by the hospital, and you can't usually bill for this service. However, if an evaluation of the underlying medical condition or disease goes beyond the normal care associated with the procedure, you can report a separate E/M code.

Consultations Are Separately Identifiable

Scenario 1: An internist admits a patient to the hospital due to painful urination (ICD-9 788.1, Dysuria) and bleeding during urination (599.7, Hematuria) and requests that a urologist perform a consultation.

The urologist reviews the patient's medical records and then determines that a prostate-specific antigen test (PSA) and a cystoscopy are warranted to evaluate the patient's symptoms. He preps the patient and performs the cystoscopy in the hospital that same day.

Coding solution: The urologist performed a consultation, during which he made the decision for a PSA test and cystoscopic examination, which he performed later that same day.

In this scenario, you should report two hospital services. Submit 99251-99255 (Initial inpatient consultation for a new or established patient ...) based on the level of service the physician provided, Pohlig says. Then, report 52000 (Cystourethroscopy [separate procedure]). The hospital laboratory will bill for the PSA test.

Note: Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to indicate that the service is separately identifiable from the procedure, says Lisa Center, CPC, coder for the Mt. Carmel Regional Medical Center in Pittsburg, Kan.

Remember: Check with your carrier, however, because some carriers may require that you use modifier 57 (Decision for surgery) in this situation. If a urological consultation leads the urologist to perform a major operative procedure (90-day global) on the same day as the consultation, append modifier 57 to the consultation code indicating that the decision for surgery was based on the findings of this examination.

Caution: Make sure your physician meets and documents the requirements of a consultation before you report the appropriate code. See the article "Watch Out for the 4th R of Consultations" in the March 2006 issue of Urology Coding Alert for more on coding consultations.

Postoperative Care May Warrant a Separate Code

Scenario 2: Your urologist sees a patient in the office and, based on his examination, schedules a TURP for later that week. He performs the TURP a few days later in the hospital and during the procedure unexpectedly finds a large bladder mass that he biopsies. Several days later following the results of the biopsy, which revealed a malignant bladder tumor, the physician sees the patient in the office postoperatively and devises a plan of care for this tumor and discusses this with the patient.

Coding solution: The development of a new care plan and discussing management options with the patient goes above and beyond the normal postoperative care associated with a TURP. All of this represents a new diagnosis and new treatment options. Therefore, you can report a separate E/M service and can expect to be paid for this service.

For this case, report 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) for the prostatectomy procedure and 99211-99215 (Office visit for the E/M of an established patient  ...) based on the level of service the physician provided for the follow-up office visit.

Append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the E/M code to indicate that it's a separate service and to ensure payment, because this is a new unrelated problem.