Urology Coding Alert

Question: For a bladder tumor checkup/follow-up (outpatient), we have been billing CPT 52000 (Cystoscopy) and CPT 99244 (Office or other outpatient consultations) with modifier -57 for the history and physical. Medicaid will not approve it. Do you have any suggestions for what we might use to receive payment?
    
 Illinois Subscriber

Answer: If the only service you provided the patient was the cystoscopic examination - and especially if the examination revealed no tumor recurrence - you should only charge for the cystoscopy (52000, Cystourethroscopy [separate procedure]) with a diagnosis of V10.51 (History of malignant neoplasm; bladder). You may not bill for a separate E/M on the same day unless some other problem existed that required further care.
The CPT 2003 states, "The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed."
 
If a bladder tumor recurrence is found, and the urologist spends time after the cystoscopic examination
with the patient counseling and coordinating further care, you may bill an E/M service based on time alone adding modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service indicating a separate service. In the above question, you  should not use a consultation code (99244) because there is no evidence of a request for a consultation (opinion or advice). Use modifier -57 (Decision for surgery) on an E/M service only when a decision for major surgery has been made the day of or the day before surgery.