Urology Coding Alert

When the urologist performs a cystoscopy (52000) (cystourethroscopy) for hematuria (599.7) on the same day as the initial consultation, a consultation code (99241-99245) must be used along with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). If you do not append a modifier -25, you will get paid only for the cystoscopy.

When a patient presents with hematuria, the urologist must perform a cystoscopy. This gives the physician a chance to examine the urethra, bladder and ureteric openings to visualize any possible source of blood.

Although 52000 is often done in combination with other procedures, it is also often done by itself. We schedule our patients to come in just for the cystoscopy, explains Traci Evans, office manager for State College Urologic Associates of State College, Pa. We almost always schedule it for another day. But in a case of gross hematuria, the cystoscopy would be done the same day. Then, we would use modifier -25 on the consultation, she says. The rationale for this is that the patient does not walk in and announce, I have blood in my urine, give me a cystoscopy. Its up to the physician to take the history, perform the examination and engage in the medical decision-making necessary to arrive at the proper diagnostic and therapeutic course.

Before a cystoscopy, the first thing you have to do, says Angelina Arevalo, billing specialist for the Uro Center of Lebanon, Pa., is a urinalysis (81000). This is for the dipstick urinalysis that tests, among other things, for blood and microscopy. Urinalysis is mandatory for Medicare, she says. If a patient is on Medicare and is going to need a cystoscopy, the urinalysis has to be done. Health Care Fincancing Administration (HCFA) wants to make sure urologists only do a diagnostic cystoscopy when there is a reason and not on every consultation. By performing the urinalysis, the urologist can demonstrate an active source of blood in the urine. Sometimes a patient might say, I think I might have blood in my urine. But unless the urinalysis shows it, you cannot use hematuria as the reason for the procedure.

Usually, the consultation and the urinalysis is covered during the initial visit, with the cystoscopy itself scheduled for another day. Once the urinalysis confirms the diagnosis as hematuria, the cystoscopy can be scheduled. Other diagnoses that support 52000 include 788.31 (urge incontinence), 788.21 (incomplete bladder emptying) and 185 (malignant neoplasm of prostate).

Modifier -78 (return to the operating room for a related procedure during the postoperative period) should be used instead of modifier -25 when several procedures are performed for a related reason on the same day, says Arevalo. Lets say the diagnosis is abnormal prostate or abnormal prostrate specific antigen, she says. We would charge an office visit, a urinalysis, a transrectal ultrasound (76872), an ultrasound with fine-needle guidance (76003) and a prostate fine-needle biopsy (88171). I would put modifier -78 on all of these codes because they are interrelated, she says, noting that each procedure would take a minimum of 10 minutes and perhaps as long as 25 minutes each, depending on the patient.

Technically, however, no modifier is necessary for this coding sequence because they are all radiology and laboratory codes, explains Thomas A. Kent, CMM, president of Kent Medical Management in Dunkirk, Md. Some Medicare carriers may require the -78 modifier to pass their computer edits. This is a case where modifiers can be used if they help but are not technically necessary, says Kent. Note that modifier -51 would not be correct because this refers to multiple procedures completed through the same surgical incision.

Note: Fine needle aspiration (88170-88171) codes are an exception among laboratory codes, in that they are really procedures. It is perfectly correct for the urologist to bill these codes.

There is one instance, however, when you need modifier -25: the consultation itself. You can use the same diagnosis code for the consultation and the cystoscopy. CPT explicitly states that different diagnoses are not required for reporting of the evaluation and management (E/M) services on the same date as the procedure, because the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided.