Urology Coding Alert

Urology coders need to know two main points about the new version of the Correct Coding Initiative (CCI):

Use modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) with one of the hundreds of newly bundled procedures that you code for the same day.

Dont use modifier -25 on an office visit unless you provide a significant, separately identifiable service.

Coders must remember to append modifier -25. For example, if a Medicare patient has a consultation with a urologist, and the urologist performs an ultrasound (a procedure that is now bundled with the consultation codes, 99241-99245), you must append modifier -25 to the consultation code.

The prescheduled diagnostic ultrasound has also changed. Suppose a patient comes in on Monday for a consultation and the urologist orders a scan that will be done on Wednesday. You cant code for an evaluation and management (E/M) service on Wednesday unless you provide a service that is significant and separately identifiable from the scan. Usually, these scans are done by an incident to provider, notes Morgan Hause, CCS, CCS-P, coding compliance specialist with Urology of Indiana, a 17- provider practice in Indianapolis. So all that could be billed was 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician). Now, you cannot even bill 99211, any more than you would be able to bill any E/M service that is not significant and separately identifiable from the bundled procedure. Simply adding a 99211 every time you perform a diagnostic procedure will not be correct coding.

How would Medicare respond to modifier -25 billed with 99211? Its hard to say at this stage. But Medicare has edits in its system that tally the number of times a particular service is billed and who is billing for it, explains Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a Denver-based coding and compliance consulting company. Once that level has been reached, Medicare starts investigating, says Page.

Tip: Use modifier -25 on the E/M code for private payers as well as Medicare because many private payers also use the CCI edits.

Modifier -25 May Be Familiar To Urologists

The new edits, although massive, probably wont be a big change from what many urologists are already doing. A patient may have a torsion of the testicle, but Im not sure its torsion. So I want to do an ultrasound with a Doppler, explains Mark Cendron, MD, associate professor of urology and pediatrics at Dartmouth Hitchcock Medical Center in Lebanon, N.H. The code for this procedure is 76870 (echography, scrotum and contents). At Dartmouth, as in many academic medical centers, the radiology department, and not the urology department, performs the test. But Cendron wants to be present for the test to make a clinical decision. I wont bill for any part of the radiology procedure. Ill bill just for the E/M service, he says. The radiologist performs and bills the technical and the professional component of 76870.

In a private practice that has the machine, however, the urologist may perform the Doppler ultrasound. In Cendrons scenario, bill for the E/M service and the procedure (76870). In this situation, the urologist wants the scan and the results immediately. The significant, separately identifiable procedure is the appropriate E/M service (99201-99215 or 99241-99245) depending on the documentation.