Urology Coding Alert

Question: My urologist performed a deactivation of an artificial urinary sphincter and a complex urethral catheterization. The patient had been admitted to the hospital, and our physician was called in. He listed 99222 on his hospital charge slip. How should I code for this procedure?

North Carolina Subscriber

Answer: First, report 99222 (Initial hospital care, per day, for the evaluation and management of a patient ...) as your urologist indicated on the charge slip. Then, report 55110 (Scrotal exploration) for the procedure. Append modifier 57 (Decision for surgery) to 99222 since the procedure happened on the same day as the examination and decision to deactivate the sphincter.

Deactivation of an artificial urinary sphincter often means a scrotal exploration to access the sphincter controlling mechanism. The exploration is considered a major procedure with a 90-day global. Therefore, you'll use modifier 57 on the E/M service to indicate that a decision was made at the time of the examination to do the exploration and deactivation.

Watch out: Don't append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) as this modifier indicates a separate and significant E/M service and a minor procedure performed on the same day. Also, avoid the temptation to also report 51703 (Insertion of temporary indwelling bladder catheter; complicated [ie, altered anatomy, fractured catheter/balloon]). The Correct Coding Initiative (CCI) bundles 51703 into 55110 and should not be billed as well.