Urology Coding Alert
Understand Medical Necessity for Urodynamics Coding
The basic diagnostic procedures are:
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: Some private payers will allow separate payment. They have stated that any new problem during the postoperative period can be separately reported with the appropriate modifier. Depending on the service provided, report modifier -24 or modifier -79.
Determining Medical Necessity
Outside of the global period, however, the key to reimbursement for urodynamics procedures is medical necessity, not modifiers.
A typical urodynamics session would consist of uroflow (51741 or 51736), cystometrogram (CMG) (51725 or 51726), and leakpoint pressure (LPP) tests (51795), mainly for diagnosing intrinsic sphincter deficiency (599.82), says Morgan Hause, CCS, CCS-P, coding specialist with Urology of Indiana, Indianapolis. Many private payers try to bundle 51795 into 51726 because they are performed at the same session. If you have separate reports at each machine, you can support separate billing, he says.
"We do LPP and complex CMG before sacral nerve stimulation because we want to know how the patient might benefit from a nerve stimulator," Hause says. Interestingly, a simple CMG pays more than a complex, because simple CMG requires the provider to be present throughout the test.
Code urodynamics procedures based on the result, because you are the interpreting physician. If the test result is normal, use the patient's complaint. For example, if the test reveals intrinsic sphincter deficiency (ISD), use 599.82. If the patient's complaint is stress incontinence but there is no ISD, use stress incontinence (625.6) as the diagnosis code.
Although ISD and stress incontinence are the most common diagnoses in urodynamics testing, carriers with local medical review policies for these codes have long lists of payable diagnosis codes, with some including new additions as of last fall: 598.9 (urethral stricture, unspecified) and 600.0-600.3 (benign prostatic hyperplasia).
Do not bill any of the urodynamics codes unless there is a sign or symptom of voiding dysfunction. These urodynamics procedures may not be used for screening or routine examination.
Voiding pressure studies (51795, 51797) evaluate different functions. Code 51795 measures the ability of the detrusor muscle to contract, and can detect outlet pressure obstruction. Urologists often perform 51795 with 51726 to diagnosis obstruction.
Code 51797 helps the urologist determine whether the detrusor muscle is functioning properly by comparing it to intra-abdominal pressure. Medicare allows these two codes to be billed on the same day with the provision that separate measurements be made.
The cystometrogram (51725) indicates if the detrusor muscle is functioning properly. It detects the capacity of the bladder, and abnormal detrusor sphincter contractions. If the patient's incontinence is due to stress, the cystometrogram is normal. Use 51726 when you have calibrated electronic equipment that performs simultaneous measurements of intra-abdominal, total bladder and true detrusor pressures.
A baseline EMG (51784) is performed before biofeedback begins and at the end of each biofeedback session. The EMG is done to see how the body reacts when having incontinence.
Uroflowmetry procedures (51741, 51736) measure the flow rate. Decreased flow indicates a malfunctioning detrusor due to obstructing BPH (600.0), a cystocele (618.x, 596.8), neurologic lesions or other reasons. Increased flow indicates a malfunctioning urethra, which can lead to stress incontinence or intrinsic sphincter dysfunction.
Rarely Used Codes
Two urodynamics codes are rarely used. Urology coders need to understand these procedures to use the codes properly.
Urethral pressure studies (51772, urethral pressure profile studies [UPP] [urethral closure pressure profile], any technique) are used only in the case of an artificial urinary sphincter. Carriers do not cover these tests unless other tests are inconclusive. They may be used to rule out severe urethral incompetence. Urologists use these tests to evaluate suspected cauda equina syndrome.
In stimulus evoked response (51792, stimulus evoked response [e.g., measurement of bulbocavernosus reflex latency time]), electric stimulation is applied to the clitoris or glans penis. Delayed or lack of response to the stimulation may indicate a neurologic lesion.
Add Modifier -26 Outside of the Office
Add modifier -26 (professional component) to all urodynamics codes when performed in a hospital or any other facility outside of the office, such as a nursing home, and receive payment for only the professional component.
If you own the equipment and bring it to a hospital or nursing home, continue to code all components with modifier -26. The facility should bill for the technical component, and the urologist should seek compensation for his equipment from the facility. The urologist works that out with the hospital where he or she works.
Some carriers require a local modifier whenever you perform a diagnostic test in your office, to make sure you don't bill for testing that someone else did for you. "The -ZP modifier (no purchased services) says you're using your equipment and staff," Hause says. You can also have a contractual agreement with your carrier that says you will abide by its rules.
Note: Keep all graphic records in the patient's chart; an auditor may want to see them.
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