Urology Coding Alert

Correct code selection for suprapubic catheter insertion is a true test of a coder's skills: Not only are they working with CCI Edits bundled codes but they must know their modifiers!

The main reason for inserting a suprapubic tube, procedure codes 51010 (Aspiration of bladder; with insertion of suprapubic catheter) and 51040 (Cystostomy, cystotomy with drainage), is an obstructed urethra that makes urethral catheterization difficult or if there is anticipated retention during a surgical procedure.

There are four questions you should ask yourself before deciding how to code your next suprapubic catheter insertion:

1. Is it bundled?

2. Is it not an integral part of a primary procedure or not typically performed with that procedure?

3. Is cystostomy excluded from the CPT definition of the primary procedure?

4. If performed within a global period, are there special circumstances that require the tube insertion or exchange?

If you answer "yes" to any of these questions, chances are you're going to need a modifier appended to the suprapubic catheter insertion if you want to be reimbursed.

Do the Trick With Modifier -58

For suprapubic catheters, modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) is appropriate when a more extensive procedure is required in the global period.

For example, on day one a Medicare patient has a percutaneous insertion of a suprapubic tube for urinary retention (51010), which has a 10-day global period. Unfortunately, the tube does not drain well, so the next day the patient must have a formal open suprapubic cystostomy (51040), a procedure considered more complicated and therefore more extensive than the original procedure, 51010. This second procedure can then be coded 51040-58 to indicate a more extensive procedure and be fully reimbursed.

Another circumstance that will dictate whether you should use modifier -58 is "if you know up front that you are going to be doing an additional procedure that is during the postoperative period," says Wanda Strickland, CPC, with Mid-Carolina Urology in Pinehurst, N.C. And if you are using "staged or related" as the key to determining when to use modifier -58, you have to know where to look for the documentation to support it.

Look in the history and physical report for an indication that a postoperative procedure was premeditated. "If an IVP was taken or if there was documentation in the office that a patient had right and left stone and the right was going to be treated first, leaving the left stone to be treated at a later date, this constitutes a staged procedure," says Kerry Dillon, CPC, business office manager of Greenwood Urological in Greenwood, S.C.

Here is an example of when modifier -58 is necessary to indicate a staged or related procedure: After a successful lithotripsy (ESWL, 90 global days), the urologist places a double-J stent to prevent hydronephrosis. The stent's subsequent removal a week or so later should be coded 52310-58 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple; staged or related procedure or service by the same physician during the postoperative period) and reimbursed.

Medicare's Global Surgery Policy says modifier -58 is valid under the following circumstances:

Don't make the mistake of using modifier -58 for a return to the operating room to correct a complication, or for unrelated procedures rendered during the global period, cautions Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J., in a presentation titled "Modifiers - It's All About the Money!" And don't forget that a new postoperative period begins with the use of modifier -58.

Use Modifier -78 Very Carefully

Whenever there is a complication of surgery that requires a follow-up procedure - that requires a different CPT code than the original surgery - in the operating room during the postoperative period, modifier -78 (Return to the operating room for a related procedure during the postoperative period) is the one to use, Dillon says.

For example, a suprapubic catheter is placed in the operating room several hours after a TURP, 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 better drainage and control of postoperative bleeding. The suprapubic catheter insertion should be coded 51010-78.

Some coders assume that modifier -59 (Distinct procedural service) would be more appropriate for unbundling a procedure done on the same day; however, if another modifier fits, in this case modifier -78, you should use it instead. "Modifier -59 is the modifier of last resort," advises Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in Augusta, S.C.

Dillon provides another example of when to use modifier -78: If a Medicare patient undergoes TURP, and after the procedure within the 90-day global period of the TURP the patient has to return to the operating room for control of postoperative bleeding, you will need modifier -78. Code 52214-78 (Cystourethroscopy ...).

Follow the Medicare Carriers Manual guidelines that advise coders, "the physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure," to be sure there is sufficient documentation with the claim. Jandroep reminds coders that modifier -78 does not reset the global period from the previous surgery. She also advises coders that they should document a new ICD-9 code with the procedure that warrants modifier -78.