Urology Coding Alert

Do you know when the 1997 Documentation Guidelines pay more for a service than the 1995 guidelines? Did you know there is more than one way to code a bilateral procedure? It may be time for you to review often-overlooked facets of coding it just might save you a bundle.

In a teleconference titled "Don't Let Your Urology Claims Go Down the Drain," C.J. Wolf, MD, CPC, emphasized the importance of the following three means of achieving optimal reimbursement for your coding practices.

Though urologists think the '95 Documentation Guidelines are easier to comply with, the '97 guidelines offer oft-overlooked reimbursement advantages.

But when urology offices become too familiar with one set of guidelines, they forget the potential advantage of using the neglected set of guidelines.

This lapse often plagues practices coding the genital urinary exam. Here's why.

The physical exam component is the primary difference between the '95 and '97 Documentation Guidelines. The '95 guidelines do not offer adequate single system exam requirements that recognize the genital urinary exam as a higher-paying exam unless it is combined with a complete system exam. In contrast, the '97 DGs consider site-specific, detailed exams like the genital urinary exam worthy of a higher-paying code. More specifically, the genital urinary exam would be coded 99202 under the 1995 DGs, but the same exam would be coded 99203 by the 1997 guidelines a $30 difference.

Don't worry about alternating between the '95 and '97 guidelines, because Medicare now endorses both equally for E/M codes. Medicare supports alternating between sets of guidelines because of reimbursement discrepancies in the two sets of guidelines. It's up to the physician to determine the set of guidelines used for a given encounter, Medicare asserts, as long as only one set of guidelines is used in any given encounter.

Remembering which global periods are attached to urological procedures may seem like a no-brainer, but the number of reimbursement opportunities missed because of mixed-up global periods tells another story. Let's take a look at procedures whose global periods may surprise you.

Example 1: A patient in his mid-30s presents with curvature of the penis. The physician determines the cause to be internal tissue that has turned to scar tissue on one side of the penis. The physician decides to treat this condition, Peyronie's disease, with an injection, 54200* (Injection procedure for Peyronie disease). 54200 has a  10-day global period.

Many coders assume injections have a 0-day global period because they are quick and common procedures, often performed by a nurse or physician assistant, Wolf says. When the 10-day global period for 54200 is mistaken for a 0-day global period, coders are not being reimbursed for unrelated services rendered to the patient within the 10-day global period because they don't realize modifiers are necessary in this situation. If the patient returns five days after the injection complaining of scrotal pain, you will not be reimbursed for the E/M claim if you do not append modifier -24 (Unrelated E/M service by the same physician ...) to the E/M code.

Example 2: A patient presents with suspected urinary incontinence. To test the pressure in the bladder, the physician performs a cystometrogram, 51726 (Complex cystometrogram [e.g., calibrated electronic equipment]). Unbeknownst to many coders, there is a 0-day global attached to 51726.

A 0-day global designates the procedure can only be reported once per day. Therefore, if the procedure is repeated in the same day it will not be reimbursed unless the proper modifier (-76) indicates the repeated procedure. Some Medicare carriers, e.g., New York Empire Medical, may require modifier -59 (Distinct procedural service) for payment instead of modifier -76, so be sure to check for distinct policy requirements.

When we talk about global periods, we are talking about Medicare, since most payers follow Medicare's global periods, Wolf says. But to ensure correct coding, you must check with each local payer to obtain accurate global periods.

Knowing your global periods is crucial for reimbursement given that no claims for procedures performed within a patient's global period will be reimbursed without the use of a modifier to indicate that the procedure was not part of the global package.

Bear in mind that global periods of major surgeries any CPT code with a 90-day global period include any procedures performed 24 hours prior to surgery.

"Medicare places the onus and impetus" on coders to use their modifiers, Wolf stresses. He suggests the physician and staff work together to ensure the proper modifiers are placed on unrelated procedures during a patient's global period.

Even though checking to see if a procedure is considered bilateral or unilateral may be an inconvenience, taking the time to identify procedures that warrant the bilateral modifier, -50, can yield satisfying reimbursement.

For example, an orchiectomy 54520 (Orchiectomy, simple [including subcapsular], with or without testicular prosthesis, scrotal or inguinal approach) would be properly coded with 54520-50 when performed bilaterally.

Overlooked bilateral reimbursements often result from the common misconception that Medicare has one fee for both unilateral and bilateral procedures, when in fact a lot of urology codes will be paid more when coded as bilateral procedures. Here's how it works.

Medicare assigns codes price and weight based on a unilateral or bilateral procedure. If a given code is based on the weight of its unilateral procedure, the corresponding bilateral procedure is payable by appending modifier -50 to the procedure code, Wolf says. Lithotripsy, 52353, is a procedure whose codes were weighed unilaterally when assigned a price, thereby permitting the use of modifier -50 for additional payment.

It is a good idea to keep a current list of procedures that are weighted unilateral and bilateral posted in the office for quick reference.