Urology Coding Alert

Question: One of our urologists states she did not do the entire urodynamic procedure and wants to only charge the patient for a urethra sphincter closure pressure study. This is her documentation: "The patient was asked to get into lithotomy position with a full bladder. The urethra was prepped with Betadine and the small catheter was placed into the bladder. The sphincter closure pressure was measured twice (28 & 27). The catheter was removed. The patient voided in the toilet." Can we report her work the way she's requesting?

Oklahoma Subscriber

Answer: Reporting 51727 (Complex cystometrogram [i.e., calibrated electronic equipment]; with urethral pressure profile studies [i.e., urethral closure pressure profile], any technique) with modifier 52 (Reduced services) in this situation is inappropriate. Code 51727 is a comprehensive/combination code that includes the work of 51726 (Complex cystometrogram [i.e., calibrated electronic equipment]) and VLPP (valsava leak point pressure). You should never try to unbundle these codes into their individual components.