Urology Coding Alert

If you don’t own the equipment, don’t bill the global code.

Most urologists perform radiological and diagnostic procedures both in their own office and in the hospital or other facility. To capture proper payment for those services, you’ll need to know exactly where the encounter took place. Then, you’ll use a modifier to explain the clinical scenario to your payer.

If your provider performs any service outside of the walls of your office, you will likely need modifier 26 (Professional component). That’s not the only modifier 26 situation, however. If your provider doesn’t perform the technical component of a procedure, regardless of setting, the modifier will also come in handy.

Take a look at these frequently asked questions (FAQ) — and the experts’ answers — to solidify your modifier 26 know how.

When Should I Use Modifier 26?

CPT® designed modifier 26 for use when reporting services “that are a combination of professional and technical components,” explains Yvonne Bouvier, CPC, CEDC, senior coding analyst for Bill Dunbar and Associates, LLC, in Indianapolis, Ind. When your provider only performs the professional component of the service, modifier 26 tells the payer that you are only coding for that portion of the service, she says.

You should also use modifier 26 when the provider performs a procedure with both a technical and professional component in an off-site facility, in other words, “in a place of service other than the office,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CENTC, CPCO, vice president of the coding and consulting division of J. & S. Stark Billing & Consulting, Inc., in Shrewsbury, N.J.

If the provider performs a procedure in a facility owned by another party, you must use modifier 26 on your code[s]; the facility should report the same code[s] with modifier TC (Technical component) appended, Cobuzzi says.

Why Should I Use Modifier 26?

Failure to use modifier 26 when the situation calls for it means the payer will consider your practice the global provider of the service, and the payer will reimburse you the full fee.

Fallout: This coding could “result in payers requesting a refund for payment as the result of incorrect coding,” explains Bouvier. This practice could also put you on a payer’s radar for future claim scrutiny.

What Types of Services Might Need Modifier 26?

Any time your provider interprets a diagnostic study or test that utilized equipment owned by a separate entity, have modifier 26 at the ready.

Example: During a procedure in the hospital, your urologist performs an injection of contrast material into the urethral meatus in a retrograde fashion to delineate the whole urethra and bladder radiologically (a retrograde urethrogram with fluoroscopic interpretation). The notes include a complete written interpretation indicating that the urologist read the films of this study. The documentation includes the type and size of the catheter used for the injection, the amount, name and concentration of contrast material used, and a formal full reading of the study.

Report 51610 (Injection procedure for retrograde urethrocystography) for the injection. Then, report 74450 (Urethrocystography, retrograde, radiological supervision and interpretation) for the interpretation of the study. Attach modifier 26 to 74450 to show that you are only coding for your physician’s services, not the hospital equipment. The technical portion of the fee will be paid to the hospital as they own the equipment and pay for the technician and contrast material used.

There are also codes, mostly in the radiology section and medicine testing sections of CPT®, which are divided into professional and technical components, Cobuzzi says. For example, if the urologist performs a urodynamic study in the outpatient department of the hospital using the hospital’s urodynamic equipment, you should only bill for the interpretation of the studies he performed (professional component) adding modifier 26 to each urodynamic study. Such urodynamics codes include 51728 (Complex cystometrogram [ie, calibrated electronic equipment]; with voiding pressure studies [ie, bladder voiding pressure] any technique), 51741 (Complex uroflowmetry [eg, calibrated electronic equipment]), and 51784 (Electromyography studies [EMG] of anal or urethral sphincter, other than needle, any technique).

How Do I Decide if I Need Modifier 26?

Modifier 26 hotspots include services that occur in:

• Hospital operating rooms (ORs)
• Hospital inpatients
• Hospital outpatients (OPD)
• Hospital EDs
• Laboratories
• Hospices
• Radiology clinics.

If the service occurs in one of the above listed locales, modifier 26 might be appropriate. However, this is not a hard and fast list, and you may use modifier 26 for services that occur in any setting.

Should I Check What the Other Provider Is Coding?

Opinions vary. Many coders report that they typically trust the other party to file the code based on the documentation with modifier TC appended. However, if the codes do not correspond or line up exactly as expected, you might be getting a call from the payer. For this reason, Bouvier recommends checking with the TC provider to make sure the CPT® codes match.

You can do this by asking the other provider for a copy of its claim. “If there is a discrepancy, contact the other provider and discuss” the situation before filing the claim, Bouvier recommends.