Urology Coding Alert

Question: I have a urologist who wants to bill CPT 54250 in units reflecting the number of nights the patient wears the measuring device, which is usually three nights. The American Urological Association (AUA) suggests billing the number of nights the device is worn as well. Our TrailBlazer Health Enterprises representative checked the Medicare guidelines and has advised us that the urologist may only bill for the interpretation of the test. How would you recommend billing this code to Medicare and other payers?

Virginia Subscriber

Answer: You should only bill for the interpretation of the nocturnal penile tumescence and/or rigidity test, but you should be able to do so for each night the patient wore the device. In other words, report 54250 (Nocturnal penile tumescence and/or rigidity test) for each date of service (or each night the patient wore the device). Append modifier 26 (Professional component) to each instance to indicate that your urologist only interpreted the test.

Reasoning: Since the patient wears the device at home and the urologist isn't performing the test in the office or hospital, you shouldn't report the technical component. Because the urologist will interpret each night's test, you should be able to bill the interpretation for each night. Most often, each night the test shows slightly different results as the patient gets used to wearing the device.

Warning: Some carriers will only pay for one night, but you should bill 54250-26 for each night. Your carrier, however, has the option to pay for one, two or three nights based on its own policies or local coverage determinations (LCD).