Urology Coding Alert

Don't forget to append modifier 25 when you report multiple services When your urologist performs a procedure such as a transurethral resection of the prostate (TURP), you should closely review the documentation for indications of a separately identifiable E/M service, or you may be missing out on an opportunity to report both the procedure and a separate E/M service. The following expert advice will help you determine whether the service your physician pre- or postoperatively provided constitutes an additional E/M. Documentation Must Support Separate Billing If you have a hard time determining what constitutes a separate E/M service when your urologist performs a procedure, remember that your physician needs to document a significant, separately identifiable service.
 
For every procedure your physician performs, he must complete a cursory history and physical (H&P) on the day of the procedure, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. So, to report a separate E/M service, your urologist must document a service that is above and beyond the pre- and postoperative care associated with the procedure.

u can't report a separate E/M for information that your urologist gathers for the H&P required by the hospital. This is usually an administrative H&P examination required by the hospital, and you can't usually bill for this service. However, if an evaluation of the underlying medical condition or disease goes beyond the normal care associated with the procedure, you can report a separate E/M code. Consultations Are Separately Identifiable Scenario 1: An internist admits a patient to the hospital due to painful urination (ICD-9 788.1, Dysuria) and bleeding during urination (599.7, Hematuria) and requests that a urologist perform a consultation.

The urologist reviews the patient's medical records and then determines that a prostate-specific antigen test (PSA) and a cystoscopy are warranted to evaluate the patient's symptoms. He preps the patient and performs the cystoscopy in the hospital that same day.

Coding solution: The urologist performed a consultation, during which he made the decision for a PSA test and cystoscopic examination, which he performed later that same day.

In this scenario, you should report two hospital services. Submit 99251-99255 (Initial inpatient consultation for a new or established patient ...) based on the level of service the physician provided, Pohlig says. Then, report 52000 (Cystourethroscopy [separate procedure]). The hospital laboratory will bill for the PSA test.

Note: Remember to 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 the E/M code to indicate that the service is separately identifiable from the procedure, says Lisa Center, CPC, coder for the Mt. Carmel Regional Medical [...]