Understand Medical Necessity for Urodynamics Coding
Published on Tue Jan 01, 2002
Now that Medicare is covering biofeedback and sacral nerve stimulation for incontinence, more urologists are performing the full range of urodynamics testing to gauge what, if any, treatment a patient needs. Setting up a urodynamics lab requires an investment, so it's important to know ahead of time which codes will be used to evaluate the profitability of testing.
The basic diagnostic procedures are:
51725 simple cystometrogram (CMG) (e.g., spinal manometer)
51726 complex cystometrogram (e.g., calibrated electronic equipment)
51736simple uroflowmetry (UFR) (e.g., stop-watch flow rate, mechanical uroflowmeter).
51741 complex uroflowmetry (e.g., calibrated electronic equipment)
51784 electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique
51785 needle electromyography studies (EMG) of anal or urethral sphincter, any technique
51795 voiding pressure studies (VP); bladder voiding pressure, any technique
51797 voiding pressure studies (VP); intra-abdominal voiding pressure (AP) (rectal, gastric, intraperitoneal).
Diagnostic Tests Not Part of Global Payment
If urodynamics tests are performed within the postoperative period of a surgery, they are typically denied. For example, sometimes after a TUMT (53850, transurethral destruction of prostate tissue; by microwave thermo-therapy) or a prostatectomy, uroflow testing might be needed. Medicare probably requires modifier -78 (return to the operating room for a related procedure during the postoperative period); private payers might require modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) or modifier -79 (unrelated procedure or service by the same physician during the postoperative period).
Medicare: Coding for urodynamics testing within the global period is difficult. Diagnostic tests such as x-rays are not part of the global payment for the procedure. Urodynamics testing is also diagnostic. However, since the urodynamics codes have been placed in the surgery section of CPT instead of the medicine section, the codes are subject to global surgery guidelines. If Medicare considers the problem a result of surgery, use modifier -78 to pull the testing out of the global period, says Jan Brunetti, CPC, billing coordinator for Urology Associates in Newport, R.I. For example, retention in a patient who underwent prostate surgery would probably be viewed as a complication.
When reported during the follow-up period of a surgery, the appropriate surgery modifier (-78, -79, -58 [staged or related procedure or service by the same physician during the postoperative period]) is required for the charge to be considered for payment. "It's almost a CPT anomaly that those codes are in the surgery section,'' Brunetti says. "Even the explanation of benefits says urodynamics testing is surgery. Patients often ask about it.''
Private payers: [...]
