Urology Coding Alert

Brush up on your modifiers, coders: You are your practice's best line of defense against charging out claims that payers may deny because of modifier mistakes.

Modifiers "ensure that there is accurate reimbursement" for services rendered, says Catherine Brink CMM, CPC, president of Healthcare Resource Management Inc., in Spring Lake, N.J. Modifiers indicate to the payer that though the CPT Code accurately applies to a procedure or service, the physician did something a little bit different from normal. Sometimes this difference warrants increased reimbursement.

That's why everyone in your office needs an adequate knowledge of these coding "enhancements," says Victoria Jackson, administrator and chief executive officer of Southern Orange County Pediatric Associates in southern California.

Check your modifier knowledge before you post any more inaccurate claims: Take this short five-question True/False test to see where you stand. Answers are provided by Jackson and Brink.
1. You can append modifier -22 to all services, including services that are not primary.
2. Modifier -21 appended to an E/M code indicates a very prolonged service. Use it for time spent on an E/M service that doesn't warrant bumping up your code to a higher level.
3. If you have multiple procedures provided by the same provider on the same day, use modifier -51.
4. If the physician determines that he doesn't need to do the full procedure once the procedure has started and the patient is already under anesthesia, you should append modifier -52 to that procedure code.
5. If one physician revises a urinary cutaneous anastomosis, and a general surgeon repairs the associated parastomal hernia, append the second code with modifier -80.

And now for the answers.

1. False: You should append modifier -22 (Unusual procedural services) only to your primary service, if it is greater than what is normally performed. The primary service can have any length of global surgical period. For instance, you can append -22 to services like endoscopies. You can also use -22 with assistant-surgeon services. You shouldn't, however, append modifier -22 to secondary services.

"Use of modifier -22 will demand medical review by the carrier," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook. "Send a paper, not electronic, claim and include the operative report and a short, simple layman's-terms note indicating the circumstances, i.e., bleeding, postradiation, etc." The additional documentation will substantiate the extra work, he adds, and most important, mention the extra operative time at least 150 percent more that was required for the extended procedure.

2. True: Modifier -21 (Prolonged evaluation and management services) is used when a face-to-face or floor/unit service is provided. If the time spent was greater than usually required for the highest-level E/M service within a given category, you should append the E/M code with modifier -21 if that is the case.

"Although this modifier is listed in CPT, it is rarely used and less often reimbursed," Ferragamo says. "When using modifier -21, a report may be needed and payment will be delayed because of mandated medical review."

3. False: Modifier -51 (Multiple procedures) covers related multiple procedures during the same provider session, not including those captured by add-on codes. Always check with your payer before using modifier -51.

But if you're reporting unrelated procedures that were in the same session as your primary service, you should report these "distinct" services with modifier -59 (Distinct procedural service). Distinct procedures are those not normally reported with the other procedure listed, for example, a separate incision or a different anatomic site. Modifier -59 on CPT codes other than your primary service says to the payer, "These are totally unrelated," Brink says.

You should use modifier -59 with caution. The CPT states, "Only if no more descriptive modifier is available, and the modifier -59 best explains the circumstances, should modifier -59 be used." Beware, especially, of using modifier -59 with bundled codes. Always check the National Correct Coding Initiative (NCCI) edits to make sure the codes are not bundled or mutually exclusive. You should not append modifier -59 to a mutually exclusive code, that is, one that can't possibly be unbundled.

"Modifier -59 is used to break bundled codes to achieve payment under certain clinical circumstances," Ferragamo explains. Modifier -59 is appended to the bundled component code when the component procedure is performed at a separate encounter on the same day as a comprehensive procedure, he says. For example, if a ureteroscopic ureteral stone extraction is performed in the morning, and later in the day an ESWL for a renal pelvic stone in performed on the same side, you should use 52352 and 50590-59.

You should also append modifier -59 to a bundled component code that is a distinct and separate procedure from a simultaneously performed major procedure, he says. For example, a ureteroscopic stone extraction and a balloon dilation of a true anatomic ureteral stricture are performed all within one ureter. You should code 52352 and 52344-59.

4. True: You use modifier -52 (Reduced services) for a procedure the physician aborted when he determined that the full procedure wasn't needed; the physician effectively reduced the original service. If, however, the physician stops performing the procedure because medical necessity requires it which is usually the reason a procedure is prematurely ended you would use modifier -53 (Discontinued procedure).

"Remember that if only a particular small portion of a discontinued procedure was performed and has its own identifiable CPT code, you should use that code without a modifier," Ferragamo instructs coders. For example, if a urologist plans a TURP but discontinues the procedure after the initial cystourethroscopy because of a cardiac problem, you shouldn't code a discontinued TURP, but code only for the cystourethroscopy: 52000.

5. False: The assistant surgeon modifier -80 (Assistant surgeon) does not accurately capture the general surgeon's work because he performed a separate procedure and did not really assist. Use instead modifier -62 (Two surgeons). You should use this modifier when two surgeons with different skills work together on two distinct parts of a single service.

"This modifier can now be used when two surgeons are of the same specialty but have different training and expertise," Ferragamo says. He cites the example of two urologists who perform a total cystectomy and continent urinary diversion when one performs the cystectomy and the second performs the diversion. "In this case, each should code 51596-62, and each should dictate what part of the total procedure he performed and what part the other urologist performed."

When using modifier -62, you should not also use modifier -80 as an assistant unless one of the surgeons assists for a separate, different operative procedure, he adds. "The urologist who performed the cystectomy should also charge for a radical prostatectomy, 55840-51, as well as 51596-62. In this case, the second urologist may also bill as an assistant to the radical prostatectomy, coding 55840-52-80 as well as 51596-62."