Urology Coding Alert

You might be able to report an E/M visit separate from 51798 -- find out how.

If you don't know the nuances of bladder scan coding and when you can also separately report an E/M service, you could be missing out on $66 your urologist legitimately deserves. Here are three guidelines that will ensure you're not costing your urologist deserved reimbursement by under-coding bladder scan encounters.

Avoid Always Reporting an Ultrasound Code

If you're billing an ultrasonic CPT code whenever your urologist uses an ultrasonic device to perform a bladder scan, you could be setting yourself up for denials. You need to dig into the documentation and determine why your physician performed the bladder scan.

If the scan's sole purpose was to measure post-voiding residual urine, you should always bill 51798 (Measurement of postvoiding residual urine and/or bladder capacity by ultrasound, non-imaging), says Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. Generally, you'll use this code when the urologist positions any ultrasonic scanner over the suprapubic area to measure the residual urine, says Elizabeth Hollingshead, CPC, CMC, corporate billing/coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio.

Many of these scanners actually print out an image or a tape, which should remain part of the permanent medical record. This image or tape will be your proof of the service your urologist performed and will also justify the necessity for catheterization, if performed. If the scanner doesn't print out a tape or image, (which is unusual), your urologist must document what he did and the test's actual results. "As with any other form of radiography, in order to bill for the procedure you need proof that you performed it. Our doctors use a hand held device, which gives a very basic printout," Kater says. "That printout along with a separately dictated paragraph giving the results of the scan becomes part of the patient's permanent record and the documentation which supports our billing of 51798. Some offices just dictate a separate paragraph within their progress note for the visit. We put the paragraph and ultrasound picture on a separate sheet and scan it into the patient's permanent record under office procedures."

Example: Your urologist performs a bladder scan ultrasonically to determine the postvoid residual urine (PVR) and finds that the bladder did not empty completely. He then inserts an indwelling Foley catheter to drain the remaining urine. Your urologist either includes the report from the ultrasound scanner or documents the test and results in detail. You should report 51798.

Note: Your urologist may not need to catheterize the patient because the scan tells him how much urine is left in the bladder. Therefore, you would not report 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]).

Capture Separate E/M Service

Thinking you can never bill an E/M visit when you report 51798 means that you could be costing your practice money it rightfully deserves. For instance, if you miss out on reporting 99213 (Office or other outpatient visit...), you'll cost your practice $66.74 in 2010 (the national unadjusted based on 1.81 RVUs times the 36.8729 conversion factor).

Don't miss: You can bill a separate E/M visit, Hollingshead says. "If the physician is seeing the patient for any number of LUTS (lower urinary tract symptoms) issues or BPH (benign prostatic hyperplasia), etc., it is entirely appropriate for the physician to charge both the bladder scan for the post void residual and the E/M service," she explains.

"We bill 51798 with office visits all the time," Kater says. "It is a diagnostic study even though it is in a surgical section of the CPT and globals do not apply to this code so you should be able to bill it with E/M visits.

The catch: For many payers, including some Medicare carriers, you may need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. "Even though 51798 is not subject to bundling rules, our Medicare carrier requires that we put a 25 modifier on the E/M code when we are billing for both," Kater explains. "I do believe that this is because, once again, it is a diagnostic test found in a surgical section."

Warning: Payers scrutinize separate E/Ms with 51798 very closely, so if you don't have a separate diagnostic reason for an E/M visit, they may deny your claim. You should appeal denials based solely on the fact that you used the same diagnostic code for the E/M and ultrasound services. CPT and Medicare rules will allow the same diagnosis for the E/M service with modifier 25 and the procedure on the same day and will reimburse for both with the same diagnosis, but the documentation should clearly establish that the visit's purpose was not solely to perform the bladder scan.

Skip Modifier 26

Because 51798 has no separate professional or technical component, you cannot bill only for professional services, Hollingshead cautions. There's no interpretation involved, because 51798 is only a measurement.

Here's why: Medicare's fee schedule does not split 51798 into professional and technical components, so you can't split the reimbursement by appending modifiers 26 (Professional component) and TC (Technical component).

"One way I check this is to look at the Medicare Fee Schedule," Kater advises. "All codes with TC/26 components are listed three times in succession in the fee schedule -- once with the total RVUs, once with the TC RVUs, and once with the 26 RVUs. If the code is listed once in the fee schedule, Medicare will not pay [separately] for TC/26 components." If your urologist reads the results after a separate facility performed the actual measurement, you should include the study's professional interpretation in your E/M service's medical decision making. In this case, you'll report only the E/M services for the day, which would include the urologist reviewing the result.

Alternative: If the urologist does a full pelvic sonogram (76856), an anatomical bladder sonogram (76857), or a renal sonogram (76775) -- which all have both technical and professional components -- off-site, you may report the interpretation. Append modifier 26 to any of the previously mentioned performed codes if your urologist alone (and not the radiologist) does the study's interpretation.