Urology Coding Alert

Paying attention to globals can rescue you from costly denials

Your urologist provides a consultation for a patient complaining of lower urinary tract symptoms. He performs a cystoscopy (52000) for hematuria. Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) can allow you to report the E/M code along with CPT 52000 - but do you have a legitimate case for using it? Read this expert advice to make sure.

Follow the Rules for Separate E/M

The first rule for modifier -25, says Mary M. Moore, CPC, supervisor of patient accounts at Concord Urology in Concord, N.H., is to append it only to E/M services - as the code descriptor clearly says. How do you make sure you're meeting the other requirements for modifier -25?

Make sure the E/M service "stands alone."  CMS specifies that all procedures have an E/M component. Private payers also assume that there's an inherent E/M visit built into the reimbursement for procedure codes, because most physicians do a certain amount of "visiting" with the patient before any procedure.

To get paid using modifier -25, the E/M service needs to be completely separate and identifiable from the procedure, says Christy Shanley, CPC, billing manager for the department of urology at the University of California, Irvine. In the above example, the cystoscopy is performed the same day, making modifier -25 a requirement on the consultation code, Shanley says.

Extra: Modifier -25 is also used to indicate the decision for minor surgery, Moore says. For example, "if a patient presents to the office and is evaluated with an E/M code, and the doctor decides during that visit that the patient needs to have a catheter placed because he's in retention, that would be another time to use modifier -25," she says.

You don't necessarily need separate diagnoses. CPT Codes states that an E/M service may be prompted by a symptom or condition that also prompts the urologist to do a procedure. "Remember, you don't necessarily have to have different diagnoses for the E/M service and the procedure," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York.

However: You should report separate diagnoses if you have them, Shanley says. "We try to have two separate diagnoses," she says, noting that Medicare and most private carriers prefer two.

Be aware of the global period for Medicare patients. As a rule of thumb, many practices append modifier -25 to any separate and identifiable E/M service for procedures with a global period of 0-10 days, says Raelle Branin, CPC, professional fee analyst for the department of urology at Baylor College of Medicine in Houston.

For procedures with a global period of 90 days, append modifier -57 (Decision for surgery) to any separate and identifiable E/M service, Branin says. As always, local and regional carriers differ in their application of the Medicare guidelines, and urology practices should contact their local carrier for guidance.

If denials continue, contact your carrier. Every carrier is different, and not all of them follow the coding standards. Sometimes it's best to contact those carriers that keep denying you and find out how they want it billed. If a carrier ever tells you anything that is directly against an accepted CPT/ICD-9/HCPCS coding standard, then ask for it in writing.