Urology Coding Alert

Plus: How to get a copy of our easy-to-use appeal letter When you need to report an appropriate E/M service that an insurer normally bundles into a procedure, you need modifier -25. Follow these three steps to learn when - and when not - to use the modifier, and how to win an appeal if a carrier denies your claim. 1. Know the Right Time to Code Injections and E/Ms In some circumstances, your urologist can bill for both an injection and an office visit, even though Medicare may have bundled these services in the past.
 
Example: A prostate cancer patient comes in for his regular Lupron injection.
 
How you should code: For the injection, you could report G0356 (Hormonal antineoplastic), a new injection code for 2005, along with the appropriate E/M code (for example, CPT 99203 , Office or other outpatient visit for the E/M of a new patient ...), says Lisa Dangle, CPC, office manager for Executive Men's Health in Tucson, Ariz.
 
"Typically, patients don't come in just for their Lupron," Dangle says. The urologist will usually also provide E/M services such as review of systems, checking the prostate and going over the PSA results with the patients, she says.
 
Be sure you attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M to indicate a separate service, says April Borgstedt, CPC, a coding specialist and president of Working for You Consulting in Broken Arrow, Okla.
 
Disaster averted: Although to remain compliant most carriers now accept G0351 (Therapeutic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular), private carriers may occasionally continue to request CPT injection code 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular).
 
Remember that Medicare no longer accepts this code. Ask your private payer for its injection and modifier -25 policies. In 2005 Medicare will reimburse for the injection code G0351 and an E/M service when performed on the same encounter.
 
Check Your ICD-9 Codes: Before you separate out the E/M with modifier -25, be sure the physician performed an exam that will satisfy coding and medical-necessity guidelines, Borgstedt adds.
 
For example, if the patient is new to your office, your urologist's E/M service should meet all three key elements: history, exam and medical decision-making.
 
In addition, link the appropriate ICD-9 Codes to the procedures and E/M. In the above example, link the patient's complaint of impotence (607.84, Impotence of organic origin) to the E/M service. Link ICD-9 code 257.2 (Other testicular hypofunction [testicular hypogonadism]) to the injection code G0351.
 
Heads-up: Coding guidelines and insurer's policies may not require that you use different diagnosis codes for the procedure [...]