Urology Coding Alert

For proper reimbursement, urologists should use modifiers -24 (unrelated evaluation and management service by the same physician during a postoperative period) and -79 (unrelated procedure or service by the same physician during the postoperative period) correctly when billing for procedures or services that are rendered within the global period of another procedure.

For example, lets say you perform hernia surgery (49495-49525), says Jackie Shovan, CPC, financial counselor with the division of urology at the University of Utah in Salt Lake City. Then, during the postoperative period, the patient comes in with a kidney stone. You should append modifier -24 to the office visit. The diagnosis code would be different, so you would think the payer would know it was unrelated, says Shovan.

But a different diagnosis code is not sufficient; you would also need the modifier. When the procedure is performed most likely 50590 (lithotripsy, extracorporeal shock wave) you would append modifier -79.

Payers Guidelines of Related, Unrelated Vary

Coders must be able to distinguish between related and unrelated procedures and services. The above scenario the hernia surgery and the extracorpreal shock wave lithotripsy for a hernia and for a stone clearly involves unrelated procedures. But there are gray areas. Although one insurance company may view a procedure as related to another, another payer may view it as unrelated.

Consider the example of a postoperative complication, such as an infection following a hernia repair. We need to understand that it depends on the insurance company, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant based in North Augusta, S.C. Commercial insurance companies consider postoperative complications to be unrelated. So if you are treating a postoperative infection in your office by doing an I&D [incision and drainage] and youre billing a commercial insurance company, append a -79 because the payer considers it to be an unrelated procedure.

The I&D code you would most likely use in the case of the infection following hernia repair is 10180 (incision and drainage, complex, postoperative wound infection).

For Medicare, on the other hand, modifier -79 will only be recognized for a totally unrelated problem, says Callaway-Stradley. If, for example, a patient presents with pelvic pain during the postoperative period and the physician performs a diagnostic cystoscopy (most likely 52000) and finds an unrelated problem, then modifier -79 should be used, she says.

Note: If a postoperative complication must be treated in the operating room, neither modifier -79 nor -24 would be used. Instead, append modifier -78 (return to the operating room for a related procedure during the postoperative period). Medicare and commercial payers required this modifier for a postoperative complication because they view the postoperative complication as related when it is treated in the operating room.

Code for E/M or Consult for Post-op Visit

The example of the hernia-kidney stone combination is typical. Patients who experience any kind of pain during the postoperative period tend to return to the surgeon, not their primary-care physician (PCP), says Shovan. Even if the surgery was for an inguinal hernia and the ensuing pain caused by the kidney stone is flank pain, the patient would likely call the urologist who performed the hernia surgery.

Tip: If the physician charges an evaluation and management (E/M) service, he or she would use modifier
-24 if a kidney stone was found and was not related.

But Shovan notes that patients who have never had a kidney stone or have not recently had surgery are likely to visit their PCP because of the flank pain. The PCP will then refer the patient to the urologist, who can bill a consultation providing that the referral is documented, the patient is seen, and a report is sent back to the requesting physician. It would be rare, says Shovan, for a patient to visit his or her PCP for flank pain a month or two after hernia surgery the patient would, as mentioned above, be more likely to return to the urologist. But if the patient does visit the PCP and the PCP refers him or her back to the operating urologist for a new problem, the urologist could bill a consultation (again, providing the referral is documented, the patient was seen, and the report is sent back to the requesting physician).