Urology Coding Alert

If you consider your urologist's "second look" a few days after an endourologic procedure included in the global period and not separately billable, think again especially if the urologist did more than just look.

When a urologist performs a percutaneous nephrostolithotomy or a percutaneous pelvic tumor resection, for example, procedures with 90-day global periods, the urologist will often take a second look just a few days into the postoperative period to determine whether the original surgery was complete. If the urologist deems the original procedure unsatisfactory, he may decide to perform more work, which many coders mistakenly consider included in the global surgical package of the initial surgery.

The key to getting paid for postoperative second looks is modifier -58 (Staged or related procedure or service by the same physician during the postoperative period). Typically when the urologist takes a second look, there are no new symptoms for the follow-up and no complications associated with the original procedure to indicate a second procedure. However, a visual re-evaluation of the operative field is performed during the global period of an initial endoscopic procedure, but something else necessitates a surgery or service to be performed during the global period, says Wendy Dicus, CPC, coding supervisor for Alaska Billing Services in Anchorage.

Here is an example of a postoperative second look: A percutaneous nephrostolithotomy is performed for a 2.5-cm renal pelvic stone, and two days later the urologist performs a "second-look" renal endoscopy and removes several small remaining stone fragments. To code this scenario, report 50081 for the initial procedure, 50561-58 for the second procedure.

According to CPT guidelines, appending modifier -58 indicates to the carrier "that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure [staged]; b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure."

"Modifier -58 does not require the follow-up procedure to be performed in the operating room," Dicus says.

To be paid for the postoperative second looks associated with codes CPT 50080 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm), CPT 50081 ( over 2 cm) and 50562 (Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with resection of tumor), you need to append modifier -58 to the second-look procedure, which is really a planned or staged second procedure.

Let's say a urologist performs a percutaneous resection of a renal pelvic tumor, 50562 ( with resection of tumor). He also documents in his operative report his intent to check a few days later the completion of the tumor resection. He proceeds with and completes the resection of the residual tumor. To properly code the urologist's second encounter and procedure, you should report 50562-58 for the repeat tumor resection that was prospectively planned.

If you have the necessary documentation to support appending modifier -58 with a service, you should be paid 100 percent of the fee allotted the service by the Medicare Physician Fee Schedule Database.

It's not enough to know that you may not perform a complete procedure in one session it is imperative that you put it in writing. It's also not sufficient to call postoperative procedures "staged" or "planned" after the fact simply because the urologist realizes he is going to have to do more work for a successful treatment and he wants to be reimbursed for that second procedure. If you are audited, you must show that you planned or expected to need a supplementary service, otherwise modifier -58 would be inappropriate. The urologist should document his intent to continue the service at a later date in the original procedure's operative notes and he should reference that initial procedure in the follow-up procedure's operative notes, says Rebecca Gab-Schroeder, CPC, a coding specialist in Rapid City, S.D.