Urology Coding Alert

You could be missing out on up to $350 per study by incorrectly coding in-office tests

Many urologists consider urodynamics sessions a cost-effective way to bring in additional revenue and serve patients. Your challenge is to determine how you should report these in-office services. Follow these expert tips and you'll be sure to see a flood of new reimbursement.
 
Note: Take a look at "Differentiate Between Urodynamics Tests and Codes to Ensure Clean Claims" on page 59 to learn the differences between various urodynamics studies and the codes you should report.

Question: Can we expect payment when our office's PA performs the study?

Nonphysician practitioners (NPP) such as physician assistants (PA) can perform urodynamics studies and be paid for the service as long as you follow a few rules. The level of supervision your urologist must provide for urodynamics studies depends on the type of study, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook.
 
For most urodynamics procedures, the urologist must provide direct supervision for a nurse, nurse practitioner (NP), medical technician or PA. This means the urologist must be present in the office when the NPP is performing the urodynamics.
 
Alternative: Your physician must provide personal supervision -- meaning he must be in the room where the procedure is being performed -- for the following procedures:
 

Exception: As of Jan. 1, 2000, a PA may perform the technical component of diagnostic tests under general supervision as allowed under the law of the state in which the PA practices. An NPP may bill for the technical component with modifier TC (Technical component) and receive full reimbursement, and a physician may bill for the professional component with modifier 26 (Professional component).
 
And if state law permits, an NP or clinical nurse specialist (CNS) may personally perform diagnostic tests without documentation of physician supervision, Ferragamo says.
 
PAs may also personally perform diagnostic tests, but they must be under general supervision of the physician. The Medicare Carriers Manual, Part 3, Section 2070 (now Medicare Benefits Policy Manual, Chapter 15, Section 80) states, " although an NP, CNS, and PA may not supervise an RN or medical technician for the performance of diagnostic tests under the diagnostic tests benefit (Social Security Act, section 1861[s][3]), these practitioners may provide personal supervision in the absence of a physician as provided under 1861(s)(2)(K) when under these circumstances 1861(s)(3) does not apply."
 
Best bet: For proper reimbursement, report the urodynamics services in the name of the NPP for Medicare and in the name of the supervising physician for private carriers, Ferragamo says.

Question: Will we be reimbursed for more than one urodynamics study at a time?

This answer depends on the type of urodynamics study your urologist is performing and the carrier to which you're reporting the service. "Medicare will pay for most uro-dynamic studies that you order and do. Private insurance, however, may limit the number of urodynamics studies that they allow," Ferragamo says.
 
Example: In November 2005, Aetna's National Coding Committee announced that Aetna would be considering 51795 (Voiding pressure studies; bladder voiding pressure, any technique) to be bundled into 51797 (... intra-abdominal voiding pressure [AP] [rectal, gastric, intraperitoneal]), and the carrier will only pay for 51797 when you report the two codes together. According to the American Medical Association in the December 2001 CPT Assistant, however, you may separately report 51795 and 51797.
 
When your urologist performs multiple urodynamics procedures during the same session, listing the codes in the correct order for payment is important, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis. These codes follow the multiple-procedures reduction guidelines, so you should rank the code with the highest fee first. Carriers will pay the first code you report at 100 percent, and then each additional code will be reduced by 50 percent.
 
How it works: For urodynamics, the highest paying code is the complex CMG, 51726. When your urologist performs a complex CMG along with other urodynamics tests, report 51726 first and then the other codes. Carriers will pay all the other urodynamics studies, including a cystoscopy that the urologist may perform at the same time as the urodynamics studies, at 50 percent of the global fee, Ferragamo says.
 
Remember: For Medicare claims, you must apply modifier 51 (Multiple procedures). Medicare will apply that modifier on its own, but for private carriers, experts suggest that you add modifier 51 to all performed and reported urodynamics studies after the initial code.
 
Exception: The National Correct Coding Initiative (NCCI) does include 51725 (Simple CMG) as a component of 51726, and a modifier indicator of "0" prevents you from reporting the two codes together, even with a modifier.
 
Question: How should we code a urodynamics study done 10 days after a failed microwave treatment?

Urodynamics studies are diagnostic tests, so in this case you're reporting a diagnostic test that the urologist is doing in the global period of the microwave therapy. The global period of microwave therapy is 90 days, so you're well within that. There are certain tests, studies and procedures that physicians may perform and be paid for during the global period for that procedure. Some require modifiers; some do not.
 
Coding scenario: If the patient is still in the global period after a microwave treatment and has burning during urination and the urologist performs a urinalysis (81000, Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy), that's a laboratory test and is payable without any type of modifier during the global period, Ferragamo says.
 
Bottom line: When you do a urodynamics study in the global period, it is a diagnostic test. Unfortunately, the urodynamics tests are considered surgical codes, so you will need a modifier to ensure payment.
 
Experts disagree: Some experts advise that you should use modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) with the urodynamics study code, while others suggest using modifier 58 (Staged or related procedure or service by the same physician during the postoperative period).
 
"If the urodynamics study testing is being done for something related to the surgery for which a global period exists, I think 58 is more appropriate because it does reflect that it is a 'related procedure' -- not necessarily staged -- but the definition allows for both. Reasonable minds differ on this, but I really feel 79 is a little misleading," Hause says.