Urology Coding Alert

Two recent changes one in the CPT Codes 2002 global surgery definition and another last year in the Medicare Carriers Manual allow payment for preoperative examinations and diagnostic tests conducted for medical necessity outside the global surgical package. The diagnosis codes listed must prove medical necessity for the procedure and must not be deemed routine care.

CPT Changes

The 2002 CPT directive on the global surgical package says that "subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical)" is included in the global surgical package and will not be reimbursed.

This verbiage implies that any E/M encounter including history and physical performed outside of that global period can be reported, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook. Whether carriers will reimburse for services outside of these restrictions "is a question no one has fully addressed," Ferragamo says.

Medicare Changes

CMS also indicated last year that E/M services and diagnostic tests not included in the global package are now chargeable and payable services. In Transmittal 1707 (dated May 31, 2001) to the Medicare Carriers Manual, CMS describes which E/M services are included in the global surgical package. If the evaluation is to determine the patient's risk factors before surgery, the E/M is payable under Medicare. However, the examination and diagnostic test must fulfill medical-necessity requirements, and therefore not be a screening.

E/M services and diagnostic tests not included in the global surgical package and performed for the purpose of evaluating the patient's risk of perioperative complications and optimizing perioperative care should be billed and considered for payment.

Routine care not deemed medically reasonable and necessary will be denied.

List Multiple Diagnosis Codes

For the primary diagnosis, you should report one of the following:

After the primary diagnosis, any secondary and tertiary diagnoses should be 1) the reason for the proposed surgery and 2) any medical risk factors that may be present. The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative exam (V72.81-V72.84). Most carriers want the V code first, then the code for the condition that prompted surgery, and finally the code for the medical risk that prompted the medical evaluation by the surgeon.

Risk Factors Constitute Medical Necessity

Certain medical risk factors such as bleeding disorders (286.x, Coagulation defects) malignant hypertension (401.0, Essential hypertension; malignant), and severe angina (413.0, Angina pectoris; angina decubitus) pose potential postoperative problems that need to be addressed. Most often these severe medical problems mandate a medical consultation by a cardiologist or internist. In these circumstances the preoperative history and physical by the urologist become part of the preoperative exam and are not separately billable. However, the hospital may still require a history and physical. The urologist sometimes performs this high-risk preoperative exam. Two examples demonstrate how to report the examination and the reason for it:

1. After consulting and examining a 65-year-old female, a urologist recommends a sling procedure (57288, Sling operation for stress incontinence [e.g., fascia or synthetic]). The patient accepts the doctor's recommendation for surgery, which will take place in six weeks. Because of poorly controlled hypertension, she returns for a full history and physical two weeks before the procedure. You should report the examination with an established patient code (99211-99215) based on the level of work performed. Link diagnosis codes V72.81, 788.3x (Incontinence of urine) and 401.0 to the E/M code.

2. After a positive needle biopsy (55700, Biopsy, prostate; needle or punch, single or multiple, any approach) of the prostate reveals carcinoma, a urologist recommends a radical prostatectomy. Due to personal circumstances and the banking of the patient's blood, surgery is scheduled in three months. Because of chronic lung disease, the patient returns a month before surgery for a complete history and physical. You should report 99211-99215 for the examination, linked to V72.82, 185 (Malignant neoplasm of prostate) and 492.8 (Other emphysema).

When to Use Modifier -57

Modifier -57 (Decision for surgery) must be appended to the E/M code if 1) a decision for surgery is made during the preoperative examination and 2) the services occur the day before or the day of surgery. Two examples illustrate when to append modifier -57:

1. A urologist's advice is requested on a possible bladder injury during extensive pelvic surgery in the operating room. The urologist examines the bladder, finds a small laceration and repairs it. You should report an intraoperative consultation (9925x) appended with modifier -57 and the bladder repair (51860, Cystorrhaphy, suture of bladder wound, injury or rupture; simple). Possible diagnosis codes include:

2. The urologist admits a patient to the hospital with severe hematuria (599.89, Other specified disorders of urethra and urinary tract; other specified disorders of urinary tract). Emergency evaluation reveals a large bleeding kidney tumor (189.0, Malignant neoplasm of kidney and other and unspecified urinary organs; kidney, except pelvis). After transfusing the patient overnight, the urologist performs an emergency nephrectomy the next morning. Code the hospital admission 9922x-57 and the next-day surgery 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy). Link diagnosis code 599.89 to 9922x-57 and 189.0 to 50230.

Preoperative Diagnostic Procedures Are Covered

Preoperative examinations such as cystoscopy, urodynamics or radiographic studies that aid in the choice of a procedure or in the extent of a surgery are covered. Two scenarios show the medical necessity required for carrier reimbursement for diagnostic procedures:

1. A urologist recommends prostatic surgery for obstructive disease and performs a preoperative cystoscopy to determine the type of procedure needed. When performed preoperatively, the examination is a payable procedure. You should report the procedure using 52000 (Cystourethroscopy [separate procedure]) linked to 600.0 (Hypertrophy [benign] of prostate).

2. A urologist recommends anti-incontinence surgery and performs a urodynamics study (51725-51797) because of urinary frequency. The study should be billed and is a payable service. Use diagnosis code 788.41 (Urinary frequency), says Jan Brunetti, CPC, billing coordinator for Urology Associates, Newport, R.I.