Urology Coding Alert

Documentation is key to getting reimbursed for several procedures in different sites

No matter how many coding guides, supplements and resources you collect, there's always a coding dilemma that just won't fit neatly into the scenarios described in CPT Codes or presented in the coding seminar your entire department just attended. See how our experts approach this one-of-a-kind coding conundrum and apply these concepts to your difficult cases.

Scenario: An established patient came to the office after finding blood in his urine. The urologist did a cystourethroscopy in the office and found many dilated vessels, which were the source of the hematuria. The patient also had a greatly enlarged prostate. During the cysto, the patient started bleeding. He stayed in the office for one hour; when the bleeding stopped, the urologist sent the patient home.

The patient returned later that day, complaining of urinary retention. The urologist inserted a Foley catheter and irrigated periodically for three hours, but the bleeding would not stop. He finally sent the patient to the hospital. At the emergency department, the urologist changed the Foley catheter and irrigated for another two and a half hours. The bleeding lessened, and the urologist admitted the patient. The next day, the urologist irrigated again, and a few days later the patient had a retropubic prostatectomy.

Modifiers Explain Prolonged Office Visits

The bad news: "You will probably never receive all the reimbursement you deserve for the amount of work the urologist did," especially at the hospital, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook. "Many carriers, including Medicare, will want to incorporate all the work you did on that day into a single hospital admission code. Based on that alone, you can never really receive compensation for the hours of work that transpired on that day."

The good news: The right series of codes and modifiers, along with documentation, will go a long way toward explaining the scenario to the carrier.

First: Depending on the level of E/M care your urologist provided, use a code from the CPT 99212-CPT 99215 series (Office or other outpatient visit ... established patient). Append  modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the E/M service was in addition to the cystourethroscopy the urologist also performed at the encounter.

Next: Use 52000 (Cystourethroscopy [separate procedure]) for the cystourethroscopy the urologist performed in the office. And since the urologist spent three hours irrigating the patient when he came back later in the day, you need to report one initial hour, plus four units of 30 minutes apiece. Use +99354-25 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour) for the first hour and four units of +99355-25 (... each additional 30 minutes) (put "4" in the units field of your claim form) for the additional two hours. Add modifier -25 to both codes to separate them from the E/M services the urologist provided at the original visit.

Don't forget: For the irrigation procedure, you need to report 51700-59-22 (Bladder irrigation, simple, lavage and/or instillation; Distinct procedural service; Unusual procedural services). Modifier -59 indicates a separate procedure from the earlier cystourethroscopy. Modifier -22 may allow you increased reimbursement based on the extra time spent -- but many carriers might not see it that way. Remember, when you submit claims with modifier    -22, it is imperative that you submit a claim and provide the necessary documentation to justify payment for the additional work.

Use -76 for Repeat Procedures in ED

Use 51700-59-76 (Bladder irrigation, simple, lavage and/or instillation; Distinct procedural service; Repeat procedure by same physician) for the repeat irrigation in the emergency department (ED) later the same day. Modifier-76 indicates to the carrier that the urologist performed a repeat of an earlier procedure on the same day and for the same diagnosis, in this case 599.7 (Hematuria).

Important step: Report 9922x-25 (Initial hospital care, new or established patient) for the admission from the ED (remember that the ED visit is included in this admission code when the ED visit and admission occur on the same day), +99356-25 x 1 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour) and three units of +99357-25 (... each additional 30 minutes) (place "3" in the units field) for the prolonged service spent in the ED and hospital. Again, modifier -25 is necessary to show that the E/M service is separate and distinct from the other procedures the urologist performed that day.

Afterward: For the hospital visits the next and following days, use a subsequent hospital care code from the 99231-99233 series. Use 55831 (Prostatectomy; retropubic, subtotal) for the retropubic prostatectomy. You don't need to append modifiers, says Wendy Dicus, CPC, coding supervisor for Alaska Billing Services Inc. in Anchorage -- 52000 and 51700 both have zero global days, so you don't have to worry about splitting these procedures from the global package.

Better Documentation Means a Better Chance at Reimbursement

Remember: You should also send all available documentation with this claim to help the carrier understand the clinical situations in the office and ED under which the urologist administered care.

Caution: The carrier may refuse to pay for the prolonged office visit on the same day as a hospital admission. However, you should still bill the prolonged office visit with documentation and an explanation to the carrier -- they may pay upon review. "If you suspect that the office or ED visit may be denied, as with a Medicare carrier, be sure to bill separately for the procedures performed in the office and ED [52000 and 57100]," Ferragamo says. "For your hospital admittance, use the highest visit code, 99223-25, and add all the performed work into this code."

Ferragamo also suggests that when you bill only for the hospital admission for the whole day's work, use 99356-25 and 99357-25 along with the admission code because of the extra time spent with the patient on that one day.

Editor's note: If you have a case study you would like to submit for consideration, please send it by fax, e-mail or U.S. mail.