Urology Coding Alert

Question: Can we bill for an office visit when we do an instillation?

Texas Subscriber

Answer: This frequently performed in-office procedure 51720 (bladder instillation of anticarcinogenic agent [including detention time]) can be billed with an evaluation and management (E/M) service under two clinical scenarios. In addition to the instillation code, an E/M service can be billed if there is also another significant and separately identifiable service provided.

Scenario #1: A patient complains and is examined for unrelated (to the instillation) flank pain, recent enlargement of his hydrocele, or he requests a discussion of his impotence. The appropriate way to bill is 9921x-25 (office or other outpatient visit for the evaluation and management of an established patient -significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 51720 if the patient is seen by a physician assistant or a urologist, or 99211-25 and 51720 if the patient is seen only by the nurse (under the incident to rule with the urologist in the office suite).

Remember also to bill the J code for the medication instilled: J9031 (BCG live [intravesical], per instillation). Usually, this procedure is performed by a nurse when the urologist is in the office suite (pursuant to incident to rules). Since 51720 is a non-starred procedure, the code includes all pre- and post-surgical care (51720 is a surgical code). It would be appropriate to bill for an office visit in addition to the instillation when, for example, the patient has flank pain that may or may not be related to the BCG.

The appropriate way to bill is 99211-25 and 51720, if the patient is seen only by the nurse.

In another example, a patient who desires a discussion of his impotence after the instillation would represent a significant and separately identifiable service. The urologist might examine the patient for an enlarging hydrocele something that doesnt happen often. However, if a nurse, technician, physician assistant or urologist makes an assessment and determines that the next intravesical treatment is appropriate, this assessment becomes a payable service. Bill 99211-25 for a nurse or technician (incident to), and 99212-25 for the physician assistant or the urologist.

Scenario #2: A nurse, technician, physician assistant or urologist makes an assessment and determines that the next intravesical treatment is appropriate. This assessment becomes a payable E/M service. Bill 99211-25 for a nurse or technician (incident to), and 99212-25 for the physician assistant or the urologist. A checklist is essential for documenting the E/M service. The assessment in the office is a fill-in sheet with questions reviewing all possible adverse effects of the drug. If the answer to all questions is no, an assessment has been made to give the next dose. A new sheet is completed for each treatment and becomes a permanent documentation record of the assessment.

The guidelines for separate reporting of office visits with a procedure are the same regardless of specialty. As long as the E/M visit is a separately identifiable service, and is appropriately documented, it can be reported with modifier -25 in addition to the code for the procedure. If, on the other hand, the evaluation and the medical decision-making for the procedure were performed during a previous encounter, no E/M service is billed with the procedure. An E/M service may also be billed based on the outcome of a previously scheduled procedure such as an instillation. If, for example, the physician provides counseling and/or discusses additional options for management of the patients medical condition. One may bill an E/M service based on time alone.