Urology Coding Alert

`Question: The patient is in the post-op period from having a transurethral resection of the prostate (TURP) done. The pathology showed prostate cancer. The patient then continued to have SpaceOAR™ and intensity-modulated radiotherapy (IMRT) placement. I billed 55874 and 55876-51. Medicare paid the 55874 but is denying the 55876, stating the procedure code is inconsistent with the modifier used or a required modifier is missing. Do I not need modifier 51?

AAPC Forum Subscriber

Answer: In this case, modifier 51 (Multiple procedures) may not be the only modifier you need. While modifier 51 is helpful as an informational modifier, it may not fully explain the surgical circumstances of this encounter. Instead, there may be two other modifiers that will help, depending on the documented surgical scenario.

First: Often, when urologists perform TURP procedures (52601 [Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)]) and radical resection is unfeasible, their plan of care includes a second planned procedure to place radiotherapy devices if pathology results come back positive for cancer (55874 [Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed]).

In your case, since the pathology confirmed prostate cancer and your urologist performed the TURP for that indicated condition and the SpaceOar™/IMRT are undoubtedly also for the same purpose, this would meet the “related” criteria if your urologist’s notes in the original TURP procedure mention a second staged procedure may be necessary. In that case, append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to both 55874 and 55876 (Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple).

Alternative: If your urologist did not document that they planned on placing brachytherapy devices if pathology showed cancer, you should not use modifier 58. Instead, you should append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to 55874 and 55876. If a patient requires an unplanned return trip to the operating room that is directly related to a procedure that took place within the last 90 days, you should use modifier 78.

Keep in mind: Many payers, including Medicare, add modifier 51 automatically when required so you may need to stop using it, depending on which payers you’re billing. “Medicare does not recommend reporting modifier 51 on your claim,” said Part B MAC WPS Medicare in its Modifier 51 Fact Sheet. “The processing system has hard-coded logic to append the modifier to the correct procedure code.”

Here’s why: If you bill multiple surgical procedures on the same date of service, the payer’s system must determine how to price all of those procedures, so it ranks them by the fee schedule amount. The service allowed at the highest amount is paid at 100 percent, but the second through fifth procedures performed on the same date are reduced down to 50 percent. If the services that you bill apply to multiple procedure pricing, the system will add that modifier, so it could cause the payer to cut your pay by another 50 percent if you also append the modifier to your claims.