Urology Coding Alert

Key: If your urologist performs these services, you need to report the administration code along with the appropriate supply code, based on how much of the drug the urologist gives the patient. Follow these expert guidelines to be sure you capture every part of these potentially lucrative services.

•  90765 -- Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one hour -- Use for Zometa.
• +90766 -- ... each additional hour (list separately in addition to code for primary procedure) -- Use for any drug your urologist gives after a second infusion, up to eight hours.
• +90767 --... additional sequential infusion, up to 1 hour (list separately in addition to code for primary procedure) -- Use for any drug the urologist gives after an initial infusion. This is an add-on code to 90765 and 90774 (see below), so you should not use it alone.
• +90768 --... concurrent infusion (list separately in addition to code for primary procedure) -- Use for any drug the patient receives at the same time as an initial infusion. This is an add-on code to 90765 and 90766, so you should not use it alone.
•  90772 -- Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular -- Use for testosterone injections, antibiotic injections and for other drugs such as B12 or Epogen.
•  90774 -- ... intravenous push, single or initial substance/drug -- Use this code for intravenous gentamycin injections your urologist gives.
• +90775 -- ... each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary procedure) -- Use for any additional drugs your urologist administers intravenously during the same session as above. This is an add-on code to 90765 and 90774, so you should not use it alone.
•  96402 -- Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic -- Use this code for Lupron, Zoladex and Trelstar injections.

Bonus: If the urologist performs a separately identifiable service at the same time as the injection, such as an office visit, you can report that service separately using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). If, however, the patient sees the physician for an office visit but the urologist's documentation doesn't show separate services, you may wish to report the E/M code rather than the drug administration code.

"With most insurances, you must append modifier 25 to the E/M visit. If the doctor does not list another separate and identifiable diagnosis, then we do not bill for the administration code," says Tina Lee, CPC, coding specialist for Urology Associates of Central California in Fresno.

For Medicare carriers and a few private carriers, there is an exception to this rule. When using 96402 and an E/M service, append modifier 25 to the E/M service. Then, you'll use the same diagnosis code, such as 185 (Malignant neoplasm of prostate), for both the E/M visit and for the injection code.

Example: A patient comes to your office for a Lupron injection. The urologist makes a clinical assessment through his examination that the patient can continue to receive further doses of Lupron. This assessment warrants a separate charge.

You can use established patient office visit codes 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) to report your physician's services, depending on the work your urologist performs. According to recent Medicare payment policy, you would append modifier 25 to 99212-99215 to ensure payment when you bill them with 96402.

Therefore, if the urologist provided a level-two E/M service in the example above, report 99212-25 for the clinical assessment, 96402 for the Lupron administration, and J9217 (Leuprolide acetate [for depot suspension], 7.5 mg) for the drug.

Tip: "Always try to get your physician to list two separate diagnoses when administering drugs. This way, you can bill both the admin and the E/M code," Lee says. Although this advice is helpful, it's not always necessary. Note that having these two diagnoses doesn't make both services billable. Your MD has to document at least two (for established patients) or three (for new) of the required elements to report an E/M services code

Your second step in coding for the drug administrations is to report the drug itself if your office provides the drug. You'll use the drug supply J codes to do this. See the chart below for the list of the most commonly used urology drugs and their codes.

Remember: If the urologist has the patient pick up the drug and bring it to the office, you cannot report the supply.

How it works: Look to the documentation for how many units of the drug your urologist administered. You may have to appeal and show documentation for multiple units, Lee says. "Often, the carriers, especially Medicare, will downcode the drugs units, so you have to appeal with documentation and proof of the number of units," she says.

Example: With the luteinizing hormone-releasing hormone (LHRH) drugs, typically a single unit is referred to as a "month," so you should report a three-month Lupron with three units or a six-month Eligard with six units.

Payment caution: Most carriers adjust your payment for drug codes down to the drug within the same classification with the lowest Average Sales Price (ASP), also known as applying the Least Costly Alternative (LCA). When there are two available drugs with equivalent medical efficacy, Medicare will only reimburse for the least expensive drug, regardless of the actual drug your urologist uses. For example, Trelstar became the LCA for LHRH drugs in January, says Alice Kater, CPC, coder for Urology Associates of South Bend, Ind. So regardless of whether you use Lupron, Zoladex or Trelstar, Medicare will reimburse you at the lower fee for Trelstar.

Beware: "If your state, like mine, is an LCA state, we need to be monitoring the ASP drugs, as the reimbursements can and have changed quarterly," Kater adds. Although many Medicare carriers do not adjust their payments to the proper LCA fee for the quarter in a timely manner, you will be held responsible for reporting the correct LCA. Often even after several years, Medicare requests large refunds from urologists who have been paid inappropriately higher than the LCA fees in the past.

"You may wish to put the following in your Web browser's favorites and check it frequently: www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a_2007aspfiles.asp," Kater says.