Urology Coding Alert

Don't let similarities with other modifiers foil your coding

Editor's note: This article is the second in a three-part series on correct modifier use. Stay tuned to next month's issue for helpful tips about modifiers 78, 79 and 80.

When your urologist performs a staged procedure, provides an E/M service within the global period, or participates in a surgery with another physician, knowing which modifier to append to capture full payment can be a headache. Read on to learn the in's and out's of modifiers 24, 58 and 62 and how you can avoid a modifier mixup.

"Understanding modifiers becomes increasingly more important every year," says Chandra Hines, business office manager for NC Urological Associates Inc. in Raleigh, N.C. "It is the way in which physicians can complete the sentence to insurance companies. It is the way to explain the various circumstances of procedures and services. Modifiers explain the particular circumstance surrounding that particular patient."

1. Avoid E/M Denials During Post-op Periods With 24

You can attach modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) only to an E/M code. Your physician must perform the service during the global surgical period for modifier 24 to be appropriate.

You should append modifier 24 when your urologist performs an unrelated E/M service during the postoperative period of a minor or major surgical procedure. Without this modifier, your payer will most likely deny any E/M services you report during a postoperative period. By attaching modifier 24, you are indicating to the carrier that a separate, unrelated service occurred before the end of the global surgical period.

"If we append 24, we are telling the payer we have proof on file that this is a different reason that this physician is seeing the patient within the follow-up period," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, a leading national authority on medical coding and reimbursement.
 
How it applies to you: Your urologist performs a transurethral electrosurgical resection of prostate (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]). While the patient is still within the 90-day global period of the surgery, he presents to your office for evaluation of a renal stone. You should report an established patient visit based on the level of service your physician applies using 99211-99215. Append modifier 24 to the E/M code to indicate that this office visit was unrelated to the TURP procedure.

2. Use Modifier 58 to Indicate Staged Procedure

When a patient returns to the operating room within the global period of a surgical procedure, you should consider modifier 58 (Staged or related procedure or service by the same physician during the postoperative period). You should append this modifier to the code for the second surgical procedure if the second surgery is related to the first. In other words, if the second surgery is the second "stage" of a procedure, you should attach modifier 58.

Important tip: For you to use modifier 58, your urologist does not need to know ahead of time that a second surgery will be necessary. "A lot of people make that mistake," Jandroep says. "They could actually do a procedure and think that is going to be enough, and then they have to bring the patient back to do some more, and it is staged or related to it, they just didn't know it ahead. You still use 58."

Caution: Coders often confuse modifier 58 with modifier 78 (Return to the operating room for a related procedure during the postoperative period). You should use modifier 78, however, when there's a complication, not when the second surgery is a staged or more invasive procedure, Jandroep says.

Example: Your urologist performs a TURP and then two months later removes more of the patient's prostate. You would report 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cysto-urethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) for the first procedure. Then, because the repeat TURP falls within the 90-day global period of the first surgery, you should use 52614 (Transurethral resection of prostate; second stage of two-stage resection [resection completed]) and attach modifier 58 to indicate that the second surgery is related to the original TURP.

Pointer: If your urologist performs a second surgery that is a more invasive procedure within the global period of another procedure, you can use modifier 58. For example, your physician performs an initial extracorporeal shock wave lithotripsy (ESWL, 50590, Lithotripsy, extracorporeal shock wave) to fragment a renal pelvic stone. He later performs a percutaneous nephrostolithotomy (PCNL, 50081, Percutaneous nephro-stolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm) to complete the fragmentation of the stone.

If this second procedure is within the global of the ESWL, add modifier 58 to the second procedure (50081-58) to indicate this more invasive surgery and to ensure its reimbursement. When you use modifier 58, the diagnoses you report will often be the same for both the first and second procedures. In this example, you should use 592.0 (Renal calculus) for both the ESWL and the PCNL.

3. Don't Confuse Modifiers 62 and 80

You should look to modifier 62 (Two surgeons) when your urologist participates in a surgery with another physician. For you to appropriately use this modifier, both surgeons should be working as primary surgeons and they must each have distinctly separate parts in the same CPT procedure, according to the modifier's code description.

"The key to remembering when to use this is when the surgeons need to share a CPT code," Jandroep says. "If they can find the CPT code in the CPT book that represents their work and then there is another CPT code to represent the other surgeon's work, they do not need to use modifier 62."

A common misconception, Jandroep says, is that if there are two surgeons taking part in a procedure, you should attach modifier 62 to every CPT code you report. That isn't the case. You should only add modifier 62 to a procedure code that both surgeons are reporting.

"Modifier 62 is used when you have two surgeons working together as primary surgeons but they are performing distinct part(s) of the procedure," Hines says. "Each surgeon needs to append the modifier to the same procedure code and dictate his or her unique part of surgery."

Example: Two urologists in your practice perform surgery on a patient--a radical cystectomy with a continent urinary reservoir in which one surgeon performs the removal of the bladder and the other does the continent urinary reservoir work.

Report both procedures for each surgeon, using the same procedure code (51596, Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder). Append modifier 62 to the surgical codes if one partner did the cystectomy and the other one did the urinary diversion.

Beware: Remember that you shouldn't use modifier 62 when the surgeon is performing as the assistant surgeon. In that case, you should use modifier 80 (Assistant surgeon). "There is a distinct fine line that separates the two, so we have to be very careful," Hines says.