Urology Coding Alert

Check out 3 scenarios that may let you append modifier 25 to seal the deal.

Submitting a claim including a cystoscopic examination as well as a same-day E/M service is often frowned upon by payers, but there are certain times when you are allowed to bill for both. Read on for the rundown on three acceptable scenarios, courtesy of Michael A. Ferragamo, MD, FACS, assistant clinical professor of urology at the State University of New York, University Hospital and Medical School at Stony Brook, New York.

Scenario 1: Clinical Condition Leads to 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 (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) to the E/M service and be able to bill for both the E/M and the procedure. In this case, the separate procedure is a cystoscopic examination, 52000 (Cystourethroscopy [separate procedure]).

The key: “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.”

“In the sentence above if you replace the word ‘neurological’ with the word ‘urological,’ and the urologist performs a medically reasonable and necessary full urological exam, then you should receive payment for both 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 gross hematuria and decides to perform a cystoscopic examination. If the exam is medically necessary and reasonable to help determine a diagnosis, then you should be paid for both services using modifier 25, Ferragamo says.

Diagnosis note: “Modifier 25 does not necessarily require a different diagnosis,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Per CPT®, the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. However, if you have different diagnoses, they may help support that the E/M was significant and separately identifiable. But different diagnoses are not required if the documentation supports that the work of the E/M went above and beyond that which is usually associated with the procedure.”

Scenario 2: The Patient Has Separate 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 examination as a further diagnostic procedure.

“In this case, the E/M examination for BPH did not lead to the decision to perform a cystoscopic examination,” Ferragamo explains. “The finding of microhematuria led to this decision. For this clinical scenario, the E/M and cystoscopic examinations should be separately billed and reimbursed with the diagnoses of BPH, ICD-10 diagnosis N40.1 for the E/M service and microscopic hematuria, ICD-10 diagnosis R31.21 for the cystoscopic examination.”

For this encounter, you would report 52000 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.

Scenario 3: New Findings Necessitate Special Counseling

If your urologist performs a procedure or service and the findings turn up an unexpected diagnosis or problem, and then the urologist 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 the cystoscopic examination is negative and there is no discussion or further treatment decisions made, then there would be 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, an E/M service would be provided and should be billed on time spent counseling and coordinating the patient’s future care. The E/M service should be billable with modifier 25.