Urology Coding Alert

An ultrasound often but not always should be billed with an office visit. Only by knowing the guidelines for when you can bill for an office visit can you get extra reimbursement, as well as avoid possible fraud charges for those times when billing an office visit would not be warranted.

When the diagnosis is the same for the ultrasound and the visit, submit a claim for both. Not doing so is cutting your practice out of proper reimbursement, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding, compliance, and reimbursement consulting firm based in Denver, Colo.

When to Use Modifier -25

For example, a 50-year-old patient has erectile dysfunction, but he is on Viagra. He comes in for a regularly scheduled visit, and upon doing a digital rectal exam (DRE), the urologist finds a hardening of the prostate. The physician knows from a previous workup that the PSA (prostate-specific antigen) is fine, so no biopsy is necessary. But he wants to do a transrectal ultrasound of the prostate. How would this visit be coded?

Some coders recommend using modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). You would code the office visit, which probably would be 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires a problem focused history and examination, and straightforward medical decision-making) with a modifier -25, says Laurie Slater, surgical coordinator for Urology Associates, a four-urologist practice in Wakefield, R.I. It would have to be a separately identified service. Then, you would code the ultrasound 76872 (echography, transrectal).

Even though CPT specifically states that you do not need a separate diagnosis when using modifier -25, for practical reimbursement purposes, says Slater, you do. In order to get paid, you want to show why the office visit is different from the procedure and a different diagnosis is the best way to do that. The recommended diagnoses are 607.84 (impotence of organic origin) for the office visit and 222.2 (benign neoplasm of male genital organs; prostate) on the ultrasound.

Tip: If you dont have any pathology results indicating a neoplasm, code 600 (hyperplasia of prostate), which is exclusive of benign neoplasm of prostate. Do not code the neoplasm unless a biopsy has been done.

How to Bill With No Modifier

With Medicare, you do not need to use modifier -25 on an office visit thats done with a radiological procedure, explains Page.

For instance, a 50-year-old patient comes in complaining of a slow urine stream. The urologist has not seen the patient for months. He also has a slightly hard prostate, and a normal PSA. The urologist performs an ultrasound.

In this case, the diagnosis codes would be 600 (hyperplasia of prostate), which could be used on the office visit and the ultrasound, and 788.62 (slowing stream) on the office visit alone. The urologist has to evaluate the patient to even know that theres a problem with the prostate, notes Page. After all, the patient didnt just walk in to the office and say, I need an ultrasound of my prostate. But this leads to another example.

A 70-year-old patient is feeling nervous about all the prostate cancer stories he has heard in the news. He wants to be screened.

This is an interesting case. If the doctor finds a palpable nodule, This flips the visit into a diagnostic, rather than screening visit, explains Page. The doctor will go on to do the ultrasound, and both the office visit and the ultrasound will be covered by Medicare no modifier -25 necessary. But what if the doctor checks the prostate via DRE and finds all is normal? Good news for the patient, but if the visit is just a screening and absolutely nothing is done during the visit but a DRE, then the DRE which is coded G0102 is the only thing the doctor can get paid for.

Modifier -25 Warrants Contracts With Private Payers Some coders recommend separate diagnoses when billing an office visit with an ultrasound because of their experience with private payers. If you have a payer who requires separate diagnoses, you need to discuss this with the payer. There are times when there are different diagnoses, as the examples in the above article show. But there are other times when the diagnosis is the same for the ultrasound and the visit. Nevertheless, you must still be able to claim for the office visit and the procedure, or you are cutting your practice out of proper reimbursement. Where you absolutely must change your contract is the situation that occurs when a managed care plan says you cannot perform diagnostic tests in the office. In this case, the managed care company says you must send all your diagnostic imaging procedures to a certain practice (that the managed care company contracts with at a discount). You need to explain that this is contrary to clinical indications, and that the ultrasounds need to be done in your office.