Urology Coding Alert

The rules have changed now that 51701 is no longer a starred procedure

When billing for office visits that result in urine catheterizations, you may face denials for the E/M, the catheterization and/or the catheterization kit. But if you follow these three steps, you can recoup pay for some, if not all, of these services:

1. Document Separate E/M

You should code for an office visit (99201-99215, Office or other outpatient visit for a new or established patient ...) in addition to urine catheterization (CPT 51701, Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) if documentation supports a separately identifiable E/M service. Usually, you will perform a history, examination and medical decision-making prior to catheterization.

Problem: Code 51701 is no longer a starred procedure and is now a zero-day global procedure. So, payers may include a minor pre-, intra-, and post-E/M service with the catheterization.

Solution: Show that the E/M service led you to decide that bladder catheterization was necessary, says Elaine Bloom, account coordinator for State College Urologic Associates in State College, Pa.

Here's how: Write a separate office note and procedure note, Bloom says. If you have to appeal for office visit payment, separate documentation will substantiate that you couldn't perform the procedure without the office visit.

Illustration: A patient presents with fever and a bagged urine specimen that suggests infection. The urologist decides to perform a urine catheterization to obtain a sterile urine sample for urinalysis and culture. The office note should describe the E/M service. Include the child's history of present illness, review of systems, and your physical examination findings, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York in Stony Brook. Add your assessment, such as "Fever of unknown origin" (780.6, Fever). Then, note your plan, such as "Need to do a urine catheterization to obtain an uncontaminated urine sample for urinalysis and culture."

Next: Write a separate paragraph or use a different sheet for your procedure note. After recording your pre- and post-diagnoses and your findings, record your final assessment and plan, Ferragamo says. "For instance, in your final assessment, you may determine: Child has a urinary tract infection (599.0)," he says. Your plan would then describe your antibiotic and treatment regime.

Listing the assessment and plan twice shows the payer that the urologist didn't have a final diagnosis at the E/M service's conclusion. Therefore, the office visit and examination led to his decision to perform the catheterization.

2. Report Separate Service, Procedure Diagnosis

Using different ICD-9 codes with the office visit and the catheterization will also support billing both the service and the procedure. "Insurers like having separate diagnoses for 99201-99215 and 51701," Ferragamo says.

Example: The urologist sees a patient at 10:30 p.m. for acute urinary retention due to perineal pain after a straddle injury. The insurer paid only for the established patient office visit and denied the catheterization.

In this case, Ferragamo recommends reviewing the claim's ICD-9 codes. You should use 959.14 (Injury, other and unspecified; trunk; other injury of external genitals) for the perineum injury and 788.20 (Retention of urine, unspecified) for the urinary retention, he says. Link 959.14 to 99201-99215, and link 788.20 to 51701.

3. Use Modifier -25 or -57

If you can show that the E/M service is separate and identifiable from the catheterization, and you have separate documentation for both services, you may also need to use a modifier to further describe the E/M service to the insurer before you receive separate reimbursement. Consider two possibilities: modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and modifier -57 (Decision for surgery).

Modifier -25 informs the payer that the office visit is a significant, separately identifiable service from the catheterization's minor E/M service, says Sandra Holman, a medical reimbursement specialist in Cornelius, N.C.

But not all insurers will pay for 99201-99215-25 with 51701. Payers deny the E/M as included in the catheterization, Holman says. Alternatively, insurers may include the catheterization in the office visit.

Another way: If you're faced with denials, some coding experts recommend using modifier -57 instead of modifier -25 on the E/M code. Modifier -57 indicates that the office visit led to the decision for surgery.

Modifier -57 appropriately describes many E/M-catheterization encounters. You would rarely perform a urine catheterization without performing a history, evaluation and medical decision-making, Ferragamo says. Since these components lead to the decision for catheterization, modifier -57 may be appropriate.

Many insurers, however, don't associate modifier -57 with minor surgeries, such as catheterization. "A lot of payers expect modifier -57 on E/M services associated with same-day major surgeries" as opposed to minor procedures, Ferragamo says.

Tip: Check your major payers' surgery modifier policies. "Call the company and ask if the insurer wants modifier -25 or modifier -57 on an E/M with catheterization," Ferragamo says.