Urology Coding Alert

Question: My physician saw a patient in the office for scrotal hematoma and sent him directly to the operating room for scrotal exploration and drainage. This was done as an outpatient procedure. Should I put modifier 25 on the office visit?

New Hampshire Subscriber

Answer: For the procedure, you'll report 54700 (Incision and drainage of epididymis, testis, and/or scrotal space [e.g., abscess or hematoma]). Because this is a minor procedure with a 10-day global period, you should append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the office visit code -- if you can show that the office visit was significant and separately identifiable. If the office visit was simply a pre-op workup and you can't identify a separate service in the documentation, you should only report the procedure code.

The office visit in this case was separate and significant because the urologist performed a history and physical examination to reach a diagnosis, which then led the urologist to recommend surgical intervention.

Tip: Check that your urologist's documentation supports a separate E/M service by excluding procedural items. Minor procedures contain some associated work, which CPT refers to as the code's surgical package. This includes a pre-op evaluation, the procedure, and postprocedure care for a set number of days.

Watch out: To also bill an E/M code, the service note must stand on its own. You have to have a history, examination and medical decision-making that support the office visit level you report. This cannot overlap with the procedure note. When you do have two separate notes -- one for the service and one for the procedure as in this case -- and the service note is codeable by itself, you should report the E/M service appended with modifier 25.

-- Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis.