Urology Coding Alert

Question: My urologist saw a Medicare patient who had had a TURP (CPT Code 52612, Transurethral resection of prostate; first stage of two-stage resection) - which has a 90-day global - who was retaining urine. He did a bladder scan (which is billable) but he also placed a Foley catheter (which is not billable, to my understanding) and spent 15-20 minutes with this patient. The urologist was very frustrated when I told him that he could not at least bill for the Foley also. Was I right, or am I missing out on reimbursement? Is it correct that we can only bill for post-op complications for a Medicare patient within the global period if the patient is brought back to the OR?

Michigan Subscriber Answer: There are several things you must consider when billing for services administered during the global of another surgical procedure. You must consider the carrier - in this case, Medicare - and whether the treatment is for a complication from the surgery, treatment of a new problem that arose in the global, or for treatment of a previous problem that existed prior to the surgery.

In your scenario, with the patient having Medicare insurance, if the urologist considers the urinary retention a complication of the TURP surgery, then any treatment administered out of the OR during the global is not a payable service except for the radiology service - the sonogram for residual urine.

If your urologist considers this problem new or present before surgery but not addressed by the procedure, and this problem is represented by a different diagnosis from the surgical diagnosis, you may bill for these services appending modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to an E/M service and modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) on any surgical procedure subsequently performed.

Remember: The urologist determines the nature of the clinical circumstance - whether it's a complication, new problem or old problem - and you can only bill on the basis of his clinical judgment. But also keep in mind that the urologist must be able to defend his billing position to his peers, if called on, and certainly must have the documentation to support his views.