Urology Coding Alert

What you think you know can hurt you to the tune of $15 per patient

In 2003, CPT Codes introduced code 51798 to replace a temporary G code to report bladder scans by ultrasound - and it has vexed coders ever since. The procedure, which earns about $15 each time based on unadjusted RVUs, is one of the most commonly performed in urology practices. And confusion about when it's appropriate to report 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) and what you're allowed to report with it could cost your practice a significant total.

Understanding the truth behind these six myths about 51798 coding will help make sure you're not leaving any postprocedure residual money on the table.

Myth #1: Whether the urologist takes an image during the bladder scan determines what code to use. If he doesn't take an image, report 51798. If he does take an image, report 76775 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], B-scan and/or real time with image documentation; limited).

Reality: Confusion on this point is common, especially since "non-imaging" appears right in the CPT Code descriptor for CPT 51798 . But whether or not the urologist obtains images is inconsequential. The use of the proper CPT code depends on the reason for the sonogram. The Coding and Reimbursement Committee of the American Urological Association reviewed this issue and decided, "regardless of the type of ultrasound machine used or whether an image was obtained, if the intent of the diagnostic procedure is to obtain only a postvoiding residual urine, then CPT code 51798 is appropriate."

Solution: If the urologist does the bladder sonogram primarily to determine the postvoid residual urine (PVR), use 51798 no matter what equipment the urologist uses and whether or not he derives an image from the equipment, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

If the urologist uses the sonogram primarily to view the anatomy or architecture of the bladder, and the PVR is only part of - but not the main reason for - the study, bill 76775.

"The AUA and the American Medical Association have recommended code 76775 because this is a retroperitoneal study, and the bladder is a retroperitoneal organ," Ferragamo says.

Beware: The second instance is the only circumstance in which you should bill 76775. Most urologists do a bladder sonogram primarily for PVR determination and should be billing with 51798. "You may also use code 76857 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up) when the urologist views the anatomy or architecture of the bladder," Ferragamo says.

Myth #2: You can't bill for a bladder scan and a catheterization at the same time.

Reality: This was true until July 1, 2004, when the National Correct Coding Initiative deleted the bundle that classified 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) and 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]) components of 51798. Since the codes are no longer bundled, you may report them together without modifiers, says Linda Whitson, RN, urology department manager for West Texas Medical Associates in San Angelo.

Example: The urologist performs an ultrasound for PVR and finds that the bladder did not empty completely. He inserts a Foley catheter to drain the remaining urine. Report CPT codes 51798 and 51702.

Myth #3: You should report a bladder scan as a diagnostic radiology procedure.

Reality: Although it seems that 51798 should be considered a diagnostic radiology procedure that you should report as type of service "4" on your claim form, Medicare sees it differently, says Alice Kater, CPC, coder for Urology Associates of South Bend, Ind. CMS assigns 51798 a TOS code of "2," designating it as a surgical procedure. CPT code 76775, meanwhile, has a TOS code of "4."

Why? CPT code 51798 is in the middle of a range of codes (50548-55845) that the Medicare Claims Processing Manual (section 10.7) designates as TOS type "2." The reason 51798 is also TOS type "2" is "because it's in the surgery section," Kater says. If you report 51798 with a "4" instead of a "2" in the TOS column, she warns, your carrier is likely to deny your claim.

Myth #4: You can't report an evaluation and management service and a bladder scan on the same day.

Reality: You should be able to bill for both if the urologist performs both, Whitson says. In the Medicare fee schedule database, CPT code 51798 has an "XXX" global period, which means that the global concept does not apply. The problem is that many carriers don't recognize that, the AUA says. "This procedure should be treated as a radiological procedure and be reimbursed in addition to any surgical procedure or E/M service," the association says. "The postvoiding residual urine diagnostic test is a tool to diagnose problems of the bladder that cannot be established through only an evaluation and management service."

Do this: If your carrier denies your claim of 51798 with an E/M service, the AUA recommends that you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and appeal - although the association stresses that such steps should not be necessary.

Helpful: The AUA also offers an appeal letter to send to carriers that deny claims of 51798 with an E/M service. You can download it from www.auanet.org/coding/reimburse/appeal.cfm.

Myth #5: Bladder scans have a professional component and a technical component.

Reality: Medicare's fee schedule does not split 51798 into professional and technical components, so you can't split the reimbursement by appending modifiers -26 (Professional component) and -TC (Technical component).  If your urologist reads the results after a separate facility performs the actual measurement, you should include the professional interpretation of the study in your documentation and the work that supports your charge. Bill only for your E/M services for the day, which would include the urologist's reading the sonogram, Ferragamo says.

Myth #6: You can only bill for 51798 when the urologist performs it in the office.

Reality: Check your Medicare carriers for local coverage determinations (LCD) or local medical review policies (LMRP), Ferragamo says. Although many carriersmay still only pay for 51798 under part B when done in the office (place-of service-code 11), some carriers, such as Empire Medicare Services of New York and New Jersey, will reimburse elsewhere. In November 2004 Empire revised its LCD to include the following POS codes: home (POS code 12), assisted living facility (13), group home (14), nursing facility (32), and custodial care facility (33).