Urology Coding Alert

Review these clinical examples that support using 25.

There are three clinical scenarios when your urologist should be paid for an E/M service performed on the same day as a cystoscopic examination, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. Read on to find out when you should be able to legitimately seek E/M payment using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Option 1: Separate Patient Problems

When your urologist performs an E/M service for one diagnosis or problem, and then performs a cystoscopic examination for a completely different problem or diagnosis, you should bill with modifier 25 and should be paid for the E/M visit and the cystoscopic examination.

Example: Your urologist sees a patient in the office in follow up for mild symptoms of an enlarged prostate gland secondary to benign prostatic hyperplasia (BPH), and finds that the patient is doing well on medication. The urologist renews his prescription for Flomax, but makes no changes to the course of treatment. During the same encounter, however, your doctor finds microscopic hematuria on urinalysis for the first time for this patient. Your urologist decides to perform a cystoscopic exam.

“In this case, the E/M examination for BPH did not lead to the decision to perform a cystoscopic examination,” says Ferragamo. “The finding of microhematuria led to this decision. For this clinical scenario, the E/M and cystoscopic examinations should be separately billed and reimbursed.”

For this encounter, you would report 52000 (Cystourethroscopy [separate procedure]) for the cystoscopy and the appropriate E/M code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient …) with modifier 25 attached.

“If a patient is being evaluated and managed for a condition separate from the condition or the reason for the … procedure, that is a service provided that should be separately payable; it would make no sense to deny payment if the two are unrelated,” says Jonathan Rubenstein, MD, director of coding and physician compliance for Chesapeake Urology Associates in Baltimore.

Option 2: Condition that Prompts a Procedure

If your urologist sees a patient who has a clinical problem that prompts both an E/M visit as well as a procedure, you should append modifier 25 to the E/M service and bill for both the E/M as well as the procedure (a cystoscopic examination).

“You have to ask yourself ‘is it reasonable and medically necessary to examine the patient and did the findings also prompt you to do a cystoscopy?’ If the answer is yes, you should be paid for both the E/M service and the cystoscopy,” Ferragamo says.

According to the Correct Coding Initiative Policy Manual, chapter 1, “If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.”

“If you replace urological for neurological, and the urologist performs a medically reasonable and necessary full urological exam, then you should receive payment for the E/M and procedure,” Ferragamo says.

Example: Your urologist sees a new patient with gross hematuria and performs a significant history and examination. He confirms the diagnosis and decides to perform a cystoscopic examination. If the exam is medically necessary and reasonable, then you should be paid for both services using modifier 25, Ferragamo says.

Option 3: New Findings Leading to Counseling

If your urologist performs a procedure or service and the findings turn up an unexpected diagnosis or problem and discusses this with the patient face to face, you may be able to also report a separate E/M service based on the time spent with the patient counseling and coordinating future care.

Example: A patient undergoes a surveillance or observation cystoscopy in follow up for a recently treated bladder tumor. The procedure was planned ahead of time. If nothing is found during the cystoscopy and there no discussion or further treatment decisions, then there’s no billable E/M service. If, however, the cystoscopic findings reveal a new bladder tumor, and the urologist then performs an office visit to discuss the findings and treatment (TURB) for the tumor, things change. In that case, because the cystoscopic findings prompted the E/M both should billable with modifier 25.