Urology Coding Alert

Urologists may bill an E/M service in addition to a catheterization (53670*) if the former is significant and separately identifiable.

Usually, a patient comes to you to find out what the problem is, not because he or she knows a catheter is needed, says Charla Prillaman, CPC, CHCO, AAPC coder of the year and senior consultant in the healthcare division of Webster, Rogers & Co., a CPA firm based in Florence, S.C. The patient is coming to you to evaluate his or her condition. This is what makes the billing of a separate E/M service appropriate.

For example, the urologist performs a consultation because the patient is having difficulty urinating. After taking a history and examining the patient, he or she diagnoses retention of urine (788.2x). In this case both the catheterization and an E/M service, with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended, may be billed.

In another example, a urologist performs a catheterization to obtain a clean-catch specimen in a female patient. The patients primary care physician (PCP) referred the patient because of burning and frequency. Prior to the service, however, the urologist must evaluate the problem. If the physician determines that catheterization is the proper diagnostic tool, then it will probably be a significant and separately identifiable service, Prillaman says.

Even if the PCP thinks that the patient may have a urinary tract infection (UTI, 599.0) and says so in the referral letter, the urologist must perform his or her own evaluation and management of the case. For example, Prillaman says, the urologist may need to consider bladder cancer. The more possible diagnoses that can be documented, the stronger the justification for billing the consultation in addition to the catheterization.

In another example, a patient has a permanent catheter and is complaining of abdominal pain. After the history and examination, the urologist concludes that the catheter isnt working. The catheter is removed and replaced. This E/M qualifies as a separate service and should be billed with modifier -25 appended.

In the above example, you may not bill for simple catheter removal. If you have trouble removing the catheter for instance, if the valve is obstructed and you have to cut it, or you must use a needle to puncture the balloon report 53675 (catheterization, urethra; complicated [may include difficult removal of balloon catheter]), says Michael Ferragamo, MD, clinical assistant professor of urology at the State University of New York in Stonybrook.

Separate Diagnoses Arent Necessary

According to CPT and Medicare rules, a separate diagnosis is not necessary when billing an office visit, with modifier -25 appended, in addition to [...]