Urology Coding Alert

Question: On June 4, 2010 another clinic performed an interstim staged procedure (CPT 64581 ) which has a global period of 90 days and at the same time they performed a laparoscopic sacral colposuspension with a cystocele and rectocele repair, plus paravaginal defect repair for myofascial pain and stress urinary incontinence. Right after surgery, the patient was told to return home and to call our office and that we would handle the rest of her care. No one from the other clinic has ever called our office to discuss this patient. The patient returned from the Jacksonville, Florida linic to the Kansas City area. She called our office on June 9, 2010 and requested further follow up from our office. We saw this patient that day for the first time (new patient) for an office assessment. She was scheduled for neurostimulator pulse generator implantation surgery on June 21. I have two questions on coding this case: Since she is a new patient to us, and we had to do a complete assessment, can we charge an office visit on June 9? Also, since we did not do the interstim staging is there anything special we need to do when we bill for the permanent pulse generator implantation (64590)?

Kansas Subscriber

Answer: Billing and coding for your office visit and scheduled surgery will depend on how the Florida clinic coded their claim.

Option 1: If the major surgical procedures performed in Florida were billed globally -- meaning that the clinic charged for the procedures and for postoperative care -- any services that you provide will be independent of all claims submitted in Florida. In this case, you should report a new patient visit for the office assessment (99201"99205, Office visit for the evaluation and management of a new patient ...) and for the surgical procedure (64590, Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling) without any modifiers.

Option 2: If the Florida clinic billed only for the surgery -- adding modifier 54 (Surgical management only) to all surgical CPT codes they reported and leaving all postoperative care to your office when the patient returned to Kansas -- you should also bill the same surgical codes billed in Florida. You'll add modifier 55 (Postoperative management only) to each code to indicate that your office is providing the postoperative care. Based on your question, you would report 64581-55 (Incision for implantation of neurostimulator electrodes; sacral nerve [transforaminal placement]). The dates of services and diagnoses for your claim should be the same as those used in Florida for their surgical procedures.

Seeing the patient at least once in your office during the postoperative period will satisfy the criteria for the above billing and coding. Also remember to note in your medical record and on the insurance claim the date you accepted the patient for follow up postoperative care. Since your office is providing this care (in other words, covering for the Florida group), add modifier 58 (Staged or related procedure...during the postoperative period) to 64590 when performed since you will be in the global period of the interstim procedure performed in Florida.

Good practice: You should speak with the Florida clinic to check on their coding, diagnoses, dates of care, and discharge, and whether they did in fact append modifier 54 to their surgical claims.