Urology Coding Alert

Medicare covers multiple urodynamics tests, but some private payers dont. Across the country, urology coders have been getting denials when using code 51726 (complex cystometrogram [e.g., calibrated electronic equipment]) along with:

51736 simple uroflowmetry (UFR) (e.g., stop- watch flow rate, mechanical uroflowmeter);

51741 complex uroflowmetry, (e.g., calibrated electronic equipment);

51795 voiding pressure studies (VP); bladder voiding pressure, any technique; or

51797 voiding pressure studies (VP); intra-abdominal voiding pressure (AP)(rectal, gastric, intraperitoneal).

Medicare doesnt bundle these codes with the cystometrogram (51726). Some private payers, however, want to save money by bundling these codes. But if you can prove medical necessity, you can be reimbursed for each study. Support medical necessity by diagnosis codes and, if needed, a letter explaining specific circumstances relating to a particular patient.

All five of these procedures present a complex evaluation to diagnose and treat a patient with a voiding problem, says Ira G. Keselman, MD, FACS, of Shore Urology in Long Branch, N.J. These procedures are needed to determine whats going on with the bladder and to detect other problems with the detrusor muscle and the sphincter. At Shore Urology, all urodynamics procedures are performed in an ambulatory surgery center, says Keselman. In some practices, the procedures are performed in a hospital. If the urologist interprets the readings but does not own the equipment, append modifier -26 (professional component) to the procedure code.

How the Five Codes Work Together

Keselman describes the five codes, and explains why they are necessary in combination when assessing a patient. Look for signs and symptoms in the urologists documentation to determine medical necessity for appropriate coding.

Cystometrogram (51726) The cystometrogram is the only one of these five procedures that involves filling the bladder with a fluid via a catheter to perform the test. The cystometer measures the bladder capacity, or bladder pressure. A complex cystometrograph measures the subtracted pressure from the bladder pressure and the abdominal pressure so we can get the true detrusor pressure, explains Keselman. We can tell the difference between an involuntary detrusor contraction and incontinence. This is the procedure that some private payers want to bundle with the other four procedures.

Flow studies (51736 and 51741) The flow rate tells the urologist how the bladder is functioning and what the patient perceives. Flow studies can tell the urologist whether there are neurological lesions or obstruction lesions. A cystometrogram cant determine that, because a cystometrogram measures bladder content rather than bladder function. A uroflow, simply, is a measure of how much liquid is urinated, in cubic centimeters, per second. The rate is the ratio of volume over time. For example, a urologist may be watching a patient who has symptoms of outlet obstruction, as in prostatism. To gauge how well the patient is responding to medication meant to shrink the prostate, the urologist performs a uroflow study. The flow rate may be 15 three months into treatment, compared to a flow rate of three before treatment, clearly demonstrating an improvement. Normally, says Keselman, the flow rate is measured just before and just after the cystometrogram. Reimbursement for flow studies includes pre- and post-testing, so you can bill only one unit. Keselmans practice performs complex uroflow studies, and bills 51741. (Use 51736 for simple uroflow studies when appropriate.)

Voiding pressure studies (51795 and 51797) Voiding pressure studies look at the simultaneous pressure of the detrusor muscle and the ureter. Any obstruction can increase contractions in the bladder. A voiding pressure study would never be done by itself, says Keselman. The voiding pressure would only tell you the pressure or the capacity, he says. But it would help you, with other tests, determine what was causing the problem.

If there is an outlet obstruction, concludes Keselman, the cystometrogram wont help the urologist discover it because there is already a catheter into the bladder for a cystometrogram. For example, if the prostate is enlarged, causing the voiding problem, the catheter used for the cystometrogram would bypass that obstruction.

Furthermore, if there is a neurological lesion, the cystometrogram wouldnt reveal it because it is a static, passive test involving filling the bladder via catheter.

Urologists need to perform more studies than a cystometrogram when evaluating patients with voiding problems. Yet, when dealing with non-Medicare payers, they may have to appeal if the payers deny payment for studies that are bundled with 51726. These are the five codes that we bill when we do a uroflow evaluation If they deny, we will appeal. says Scott Radle, business manager for Accent Urology, a two-urologist practice in St. Louis, Mo. If urologists document medical necessity for performing these procedures, it will help prevent denials.