Urology Coding Alert

Hint: Don't forget E/M could be allowed with 51798.

Trends during the past several years have included seeing more urologists (and other specialists) perform scans in their offices instead of hospital settings. One prime example from urology practices is the bladder scan, which is sometimes handled differently than other common scans. Our experts offer real-world advice to explain bladder scan coding.

Begin With the Correct CPT^® Section

For diagnostic ultrasound codes, look in the radiology section of the CPT^® book (the 7xxxx codes) for most of the codes, instructs Michael A. Granovsky, MD, FACEP, CPC, president of LogixHealth, a medical coding and billing company in Bedford MA. This is the correct first step for the majority of procedures, but not bladder scans. Instead, you'll stay in the urology section with 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging).

You'll typically report 51798 when the urologist positions any ultrasonic scanner over the suprapubic area to measure residual urine.

Bonus: Most of the scanners print out an image or tape that can become part of the patient's permanent record. This image will serve as proof of the urologist's service and will also help justify catheterization, if needed. However, remember, this is a "non-imaging" sonogram so an image or tape is not required for payment, points out Michael Ferragamo MD, FACS, clinical assistant professor of urology, State University of New York.

Backup option: If the scanner doesn't print out an image, the physician should clearly document his work and the test results.

Know What Work Is Included In 51798

Many imaging codes include both technical and professional components, but that isn't the case with 51798.

What it means: Because code 51798 has no separate professional or technical component, you cannot bill only for professional services. There's no interpretation involved, because 51798 is only a measurement. Modifiers such as 26 (Professional component) and TC (Technical component) are not needed since the Medicare fee schedule doesn't split 51798 into the separate components.

Also: There is no physician work (work relative value units, RVUs) associated with 51798, which means it carries a work value of zero. Code 51798 represents a reading and payment is based solely on this measurement of volume.

You should be able to bill 51798 for both Medicare and non-Medicare payers in any location (office or hospital) as this is a radiology code and is not included within a global period, meaning the global concept does not apply.

Let E/M Selection Sometimes Cover the Work

Because 51798 is considered a "reading" code, you can potentially report a separate E/M code to help cover code 51798's work. The ultrasound/scan may contribute to the overall medical decision making (MDM), Granovsky says.

Example: The urologist reads the results of the bladder scan after a separate facility performs the actual measurement. You should include the professional interpretation of the study in your documentation of the medical decision-making portion of your E/M service. Bill only for your E/M services for the day, which would include the urologist's reading the sonogram.

Caution: For many insurers, including some Medicare carriers, you may need to 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 code. The payers are scrutinizing separate E/Ms with 51798 very closely, so if you don't have a separate diagnostic reason for an E/M visit, they may deny you payment. CPT^® and Medicare rules will allow the same diagnosis for the E/M service with modifier 25 and the procedure on the same day and should reimburse for both even with the same diagnosis.

Remember MD Might Not Have to Be Present

Code 51798 falls under the classification of "general supervision" in terms of the physician's work. This means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the procedure, according to Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac Medical Practice Consulting in Clearwater, Fla.

"The physician must order the diagnostic test but does not have to be in the office at the time of the performance of the test," she explains. The physician is responsible for training the people who do the tests, as well as maintaining the testing equipment.

Don't Miss Other Code Opportunities

Depending on the scan's results, the urologist might perform an additional service during the same encounter. If so, there's a good chance you can report that second service based on documentation.

Example: Your urologist performs a bladder scan ultrasonically to determine the postvoid residual urine (PVR) and finds that the bladder did not empty completely, and the patient may be in urinary retention. He then inserts an indwelling Foley catheter to drain the remaining urine. Be sure the urologist either includes the report from the machine or documents the test results in detail. Then, report 51798 and 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]). You don't need any modifiers when you use these two codes together because 51798 is a radiological code and 51702 is a surgical code.

Pay attention: Documentation for 51798 requires measurement and reporting the amount of residual urine and the method of obtaining the residual urine either via sonography or catheterization. When the provider performs a more extensive sonographic examination of the total bladder, viewing full and complete bladder anatomy and any abnormalities as well as residual urine, bill CPT^® code 76857 (Ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles]).

"Documentation of a total bladder ultrasound (76857) should include measurements of the thickness of the bladder wall, the presence of any diverticula (small out-pocketings through the bladder wall), any stones present within the diverticula, the bladder interior including presence of any tumors or stones, and for male patients demonstration of an enlarged prostate gland deforming the bladder floor and base," Ferragamo explains.