Urology Coding Alert

CMS says some might be misvalued – which could hit your bottom line.

According to information in the 2017 Medicare Physician Fee Schedule Proposed Rule, CMS believes that reviewing procedure codes typically billed with an E/M service and modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day…) as potentially misvalued could be one way to review how these services really should be valued and paid.

What it means: One result of this belief is that CMS developed a proposed list of potentially misvalued services in this category, by identifying zero-day global codes billed with an E/M 50 percent of the time or more, on the same day of service, with the same physician and same beneficiary. Priority review of these potentially misvalued services will be based on codes that have not been reviewed in the last five years that have utilization of greater than 20,000 allowed services, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a coding and billing company in Bedford, Mass.

Table seven, “000-Day Global Services Billed with E/M,” in the proposed rule lists 83 codes that meet the review criteria that CMS is proposing as potentially misvalued for CY 2017. The agency is requesting public input on additional ways to address appropriate valuations for all services that are typically billed with an E/M with modifier 25 appended.

Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York at Stony Brook, gives the following urological services as examples of those that have been considered misvalued or overpaid:

• 51700 – Bladder irrigation, simple, lavage and/or instillation
• 51702 – Insertion of temporary indwelling bladder catheter; simple (e.g., Foley)
• 51720 – Bladder instillation of anticarcinogenic agent (including retention time)
• 51784 – Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique
• 51798 – Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging
• 52000 – Cystourethroscopy (separate procedure)
• 55700 – Biopsy, prostate; needle or punch, single or multiple, any approach.

Bottom line: You’ll want to monitor this issue in the final rule to see how it might impact your 2017 coding, warns Granovsky.