Urology Coding Alert

Determine when you should append 25, 57 and 59

Note: This article is the first in a three-part series on correct modifier use. Stay tuned to next month’s issue for helpful tips about modifiers 24, 58 and 62.

If you are appending incorrect modifiers to your codes or skipping them altogether, you’re setting yourself up for denials and lost reimbursement. By understanding the modifiers that urology coders often use, you can avoid those problems.
 
“Modifiers are a significant and important part of coding,” says Tina Miller, CPC, with Urology Associates of Central California in Fresno. “They can help connect or separate the CPT Codes from each other so that the insurer has a clear and concise picture of what was happening in the office or hospital setting.”

Use Modifier 25 Only on E/M Services

You can append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) only to an E/M service code. You can consider modifier 25 applicable to decisions for minor surgery, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, a leading national authority on medical coding and reimbursement.
 
Remember: To append modifier 25 to an E/M code, you should have documentation that shows a significant, separate service.

How it works: An established patient comes in for an office visit and presents with lower-urinary-tract obstructive symptoms. Your urologist examines the patient and diagnoses benign prostatic hyperplasia (BPH). The physician also elects to perform cystoscopic examination for microhematuria discovered during the same office visit.

You should report the office visit using one of the established patient codes, 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). Because the physician performed the cystoscopy on the same day, you need to add modifier 25 to the E/M code.

Appending modifier 25 demonstrates that the office visit relates to the patient’s BPH symptoms, and your payer should not conclude that the E/M service is part of the cystoscopic procedure. For the cystoscopy, report 52000 (Cystourethroscopy [separate procedure]).

In this case, you should also use different diagnoses for the E/M service and the cystoscopy. For the diagnosis of BPH, report 600.01 (Benign prostate hyperplasia, with urinary retention). You should link ICD-9 Code 599.7 (Hematuria) to the cystoscopic procedure.

Decision for Surgery Supports Modifier 57

You should append modifier 57 (Decision for surgery) to an E/M code to indicate that an appointment resulted in the urologist’s recommendation for surgery. Basically, this modifier clarifies that the E/M service provided on the day of or the day prior to a procedure was not a pre-op visit, but it led to the decision for major surgery with a 90-day global period. When you attach 57 to an E/M code, you’re indicating to Medicare or a private carrier that they should consider the E/M service part of the global package for the surgical procedure.
 
Note: You cannot use modifier 57 with the E/M code when the urologist gathers preoperative history and performs a physical prior to the surgical procedure, Miller says. This type of visit would qualify as a pre-op exam. “You can’t use modifier 57 on a pre-op exam because at that time you already know that the procedure is going to take place and that’s the reason for the visit. These are usually done a day or so before the actual procedure takes place,” Miller says.

Example: A patient with prostatism (600.91) comes into your office on a Monday. Based on his findings during the examination, the urologist schedules a transurethral resection of the prostate gland for Tuesday. Unless you add modifier 57 to the E/M code for the office visit, you won’t get paid for it because the visit took place within 24 hours of the major surgical procedure, which is within the global period.

Report one of the E/M office visit codes (99201-99215) with modifier 57, and 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete) for the surgery.

59 Does the Unbundling

You can use modifier 59 (Distinct procedural service) to override certain National Correct Coding Initiative (NCCI) edits when your urologist performs a procedure that is distinct or independent from other services performed on the same day.

Each set of bundled codes in the NCCI edits has a modifier indicator that tells you whether you should append modifier 59 to a procedure code. If the modifier indicator is “0,” you cannot use modifier 59 to override the edit. On the other hand, a “1” indicator allows you to apply the modifier to unbundle the codes.

Use caution: You should consider modifier 59 as the modifier of last resort. “If there is another modifier that will tell your story, you are to use that instead of modifier 59,” Jandroep says. You also need to be sure you have strong documentation when you attach modifier 59. Payers tend to scrutinize modifier 59 claims carefully, and they may ask you to provide documentation showing that the services were, in fact, distinctly separate.

Scenario: Your urologist performs a cystoscopy and a retrograde pyelogram to localize a stone for extracorporeal shock wave lithotripsy (ESWL). You should report the cystoscopy and retrograde pyelography separately and use  modifier 59 because NCCI bundles the procedures. First, report 50590 (Lithotripsy, extracorporeal shock wave) for the ESWL, since this is the primary or more extensive procedure.

Next, report 52005-59 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation or ureteropyelography, exclusive of radiologic service; distinct procedural service) for the retrograde study to identify the stone. Add modifier 59 to unbundle 52005 from the ESWL since your urologist won’t necessarily perform a cystourethroscopy each time he completes an ESWL.

In this case, the cystoscopy and retrograde pyelogram performed with the ESWL are distinct procedures carried out for a specific reason: to localize the stone. Following the localization, the urologist performs the ESWL. Therefore, the cystoscopy and retrograde pyelogram in this particular case are not an integral part of the ESWL, and modifier 59 is appropriate.