Urology Coding Alert

Question: Our payers often say we should add modifier 51 to 51726, 51784, 51795, 51797, 51772 and 51741. I was recently told that the reason for the audit of notes is that we sometimes use 51741 as the fifth or sixth code. Should we be using modifier 26 instead of 51? What is the best way to code these procedures?


Massachusetts Subscriber

Answer: Unfortunately, you'll find no standard for urodynamic testing, because individual payers determine how you should submit these claims. The best advice is to check your payers' specific policies for urodynamic coding and then start a dialog between your provider and the medical director to get an exception to billing several of these diagnostic, non-surgical procedures.

As for modifiers, you should only use modifier 26 (Professional component) if your urologist does not own the equipment. This would pertain if your urologist performs the studies in a hospital, inpatient or outpatient, or in a rehabilitation center where the facility owns and maintains the equipment. In this situation, your physician is only providing the interpretation of the studies, so you should append modifier 26 to each study.

The codes you mentioned (such as 51726, Complex cystometrogram [e.g., calibrated electronic equipment]) have both a technical and professional component, so you will need to be clear with the payer whether you are billing for both components (in which case, you would not use modifier 26) or only the professional component (in which case, you would). In a facility setting, you would have to use modifier 26 as well. In the office, where typically the provider owns the equipment, you won't need the modifier.

Because CPT lists these codes in the surgical section of the CPT book, you may need to use modifier 51 (Multiple procedures). Apply this modifier to all of the codes except for the code listed first. Ask your payer for its preference.

Tip: You should be certain to list the codes in order of reimbursement, listing the higher allowed service first, since the codes will be subjected to multiple-procedure reductions. Also, as diagnostic tests, these procedures are billable during global periods of other procedures, although many carriers will deny them initially unless you use an appropriate modifier.

Heads up: You'll also find that most payers will always want to review your physician's documentation when he performs more than three or four procedures on the same date, so be prepared to include it.