Urology Coding Alert

You already know that you should sequence the highest-paying procedure first on your claim when your urologist performs multiple procedures but determining the highest-paying procedure isn't always easy.

When the same physician performs multiple procedures in the same session, coders are instructed to report the primary procedure or service first, without modifier -51 (Multiple procedures), and any additional procedure(s) or service(s) performed at the same patient encounter with modifier -51 appended, "except when those additional services are represented by add-on codes, codes indicated by a '+'symbol," says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC in Indianapolis. "These are supplemental codes, which are already weighted for payment as secondary services."

According to the Medicare Carriers Manual, "When more than one surgical service is performed on the same patient, by the same physician, and on the same day: The fee schedule amount for a second procedure is 50 percent of the fee schedule amount that would have been otherwise applicable for that procedure; and the fee schedule amount for the third through fifth procedures is 50 percent of the fee schedule amount that would have been otherwise applicable for that procedure."

Coders should note that the exception to this concept is multiple endoscopic services for which the RVUs of the base code are removed before the 50 percent reduction is taken, Hause says.

How does this affect your coding? "You have to sequence the most expensive procedure first," indicating it was the major procedure performed and should be paid at 100 percent of the fee, says Janie Gram, CPC, coding specialist with Urology of Virginia in Hampton, Va.

Even though Medicare will automatically append modifier -51 to secondary and tertiary procedures, to be on the safe side you should sequence the procedure with the highest relative value units first, so you can be sure that is the procedure for which you are reimbursed at 100 percent. You are the one coding from the operative report, not the carrier, Gram says, so only you really know what should be considered the primary procedure and paid in full.

If you aren't sure which of two procedure codes pays more, you have to consult the Physician Fee Schedule, Gram instructs coders. You can use the fee schedule amounts to determine your sequencing for non-Medicare carriers as well as Medicare carriers because they generally use a percentage of the same fee schedule, she adds.

For bladder, ureteral and pelvic tumor resections, correctly sequencing codes for tumor resections from multiple locations in the urinary tract gets confusing. Here are the codes for bladder, ureteral and pelvic tumor resections and their 2003 relative value units (RVUs) as listed in the Medicare Physician Fee Schedule Database (MPFSD):