Maximize Providers’ Time and Payment for Urodynamic Testing
Understand split billing, modifier, and copay rules for urodynamics to keep your revenue stream strong and consistent.
Urodynamics or URODS (pronounced “yur-odds”) refers to a diagnostic test that evaluates the function of the bladder and urethra. Providers order the test for patients with urinary incontinence, recurrent urinary tract infections (UTIs), incomplete bladder emptying, a slow/weak stream, frequent urination, and bladder pain. The test results provide valuable data that enable the provider to confirm a diagnosis and treat the bladder disease, accordingly. The test takes approximately one hour to complete, including the set up.
Urodynamic Procedural Coding
The following CPT® codes may be called on during a urodynamic testing encounter that uses calibrated equipment:
51728 Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (i.e., bladder voiding pressure
51729 Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique
51741 Complex uroflowmetry (eg, calibrated electronic equipment)
*This code may not always be billed if the patient cannot void at the procedure.
51784 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique
+51797 Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal)
*This is an add-on code that can be billed only with either 51728 or 51729.
For cystometrogram, the code selection is based on the equipment used. If cystometrogram is performed using electronic equipment, use 51726 Complex cystometrogram (ie, calibrated electronic equipment), not 51725.
For voiding pressure studies, if urethral pressure is done, choose 51727 Complex cystometrogram (ie, calibrated electronic equipment); with urethral pressure profile studies (ie, urethral closure pressure profile), any technique. For bladder pressure, choose 51728; if both are performed, use 51729.
For uroflometry equipment, use code 51736 Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter) for simple, mechanical uroflowmeter; and report 51741 for complex, calibrated electronic equipment.
For the electromyogram (EMG) studies, use CPT® 51785 Needle EMG of anal or urethral sphincter, any technique when needled electrodes are used, versus 51784 when they are not.
“Split” Billing for Urodynamics
It’s not always possible for the patient’s usual provider to be in the office on the same day the test can be scheduled. When this occurs, the billing and reporting of the test can be split into two separate claims. Using split billing for urodynamics testing will maximize your clinic’s scheduling options. When your provider is at a different facility performing surgeries, their patients can be checked in for urodynamics in the office setting by a non-physician provider and billed with the technical component modifier. Results are interpreted, documented, and billed at a later date by the responsible provider.
For example, your patient may have the test performed, only (without interpretation), with any available provider. The urodynamic code(s) is billed with modifier TC Technical component appended to indicate to the payer that only the technical services were provided on that date of service.
The next day (or soon after), when the physician evaluates and interprets the test data, the same urodynamic code(s) is billed again with modifier 26 Professional component appended, to indicate that only the professional interpretation of the test was done on that date of service. Each claim submission can be done by different providers.
If the payer requires it, modifier 51 Multiple procedures may be attached to indicate multiple procedures were performed at the same session. As usual, documentation must substantiate the results in the patient chart.
Patient A presents to the office for URODS, with the following note:
Because of presentation she agreed to urodynamics, using an electronic calibrated machine. A time out was performed to verify that she understood the nature of the procedure and to answer questions to her satisfaction.
After informed consent she was placed in the dorsal lithotomy position and prepped in the usual manner. The vesicle and rectal catheters were placed. Perineal EMG patches were placed. These were then zeroed per manufactures suggestions. Unless otherwise noted, filling was performed at 50 cc/min.
Findings of note:
Post void residual: 100 cc
First urge: 212 cc – Not associated with an involuntary detrusor contraction
Strong desire: 354 cc – Not associated with an involuntary detrusor contraction
Capacity: 433 cc – Not associated with an involuntary detrusor contraction
Involuntary detrusor contractions: Absent
Abdominal leak point pressure: Present at 404 cc for pressure greater than 100 cm water
Leakage elicited supine
EMG patter: Elevated
Peak flow: under 10 cc/sec and mildly prolonged
Pattern: Primary abdominal
EMG Pattern: consistent with dysfunctional pattern
The provider performing the study documents above and signs off on the chart but does not provide interpretation of the results.
Report this visit: 51728-TC, 51784-TC, 51797-TC, 1741-TC
Rationale: The provider only performed the technical component of the codes billed.
The following day, Patient A’s provider reviews the results and documents the interpretation of the URODS findings in the patient chart, as follows:
Interpretation of Studies:
Female stress incontinence. Increased EMG signals. Abdominal dysfunctional voiding. Bladder underactivity.
Report this visit: 51728-26, 51784-26, 51797-26, 51741-26
Rationale: The physician reviewed the data from the test and provided an interpretation of the results.
Note: An office visit charge is usually not billed with URODS unless the provider addresses a separate issue. For example, if the patient presents for URODS and hydronephrosis is addressed (and this is properly documented in the medical record), you can bill for the appropriate evaluation and management (E/M) level with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended, along with the appropriate urodynamic code(s).
Watch How Payers Process Patient Co-pays
Be aware of how the insurance payer processes your patient’s co-pay. Some claims processing systems are set up to assess co-pays per date of service. Occasionally, the billing may be split on two different dates of service, and payers will treat the different dates of service as separate encounters and will assess a copay for each day. Because your patient was only seen for one encounter, they should not be charged for double co-pays. If this happens, be prepared to handle inquiries from patients questioning two different dates of service on their explanation of benefits, and two assessed co-pays. Again: Patients should not be charged for two office visit co-pays.
Modifier 26 Professional component: Certain procedures are a combination of a physician or other qualified healthcare professional component and a technical component. When the physician or other qualified healthcare professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure code.
Modifier TC Technical component: Under certain circumstances, a charge may be made for the technical component of a service, alone. Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure code.
Julie C. Ordway, BBA, CPC, CPB, is accounts receivable manager for The Center for Men’s and Women’s Urology. She has over 17 years of medical office experience including billing, coding, credentialing, payroll, office manager, and human resources in specialties including ear, nose, and throat; urology; and pediatrics.