Urology Coding Alert

Determine when you should append 25, 57 and 59 Note: This article is the first in a three-part series on correct modifier use. Stay tuned to next month’s issue for helpful tips about modifiers 24, 58 and 62. If you are appending incorrect modifiers to your codes or skipping them altogether, you’re setting yourself up for denials and lost reimbursement. By understanding the modifiers that urology coders often use, you can avoid those problems.
 
“Modifiers are a significant and important part of coding,” says Tina Miller, CPC, with Urology Associates of Central California in Fresno. “They can help connect or separate the CPT Codes from each other so that the insurer has a clear and concise picture of what was happening in the office or hospital setting.” Use Modifier 25 Only on E/M Services You can append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) only to an E/M service code. You can consider modifier 25 applicable to decisions for minor surgery, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, a leading national authority on medical coding and reimbursement.
 
Remember: To append modifier 25 to an E/M code, you should have documentation that shows a significant, separate service.

How it works: An established patient comes in for an office visit and presents with lower-urinary-tract obstructive symptoms. Your urologist examines the patient and diagnoses benign prostatic hyperplasia (BPH). The physician also elects to perform cystoscopic examination for microhematuria discovered during the same office visit.

You should report the office visit using one of the established patient codes, 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). Because the physician performed the cystoscopy on the same day, you need to add modifier 25 to the E/M code.

Appending modifier 25 demonstrates that the office visit relates to the patient’s BPH symptoms, and your payer should not conclude that the E/M service is part of the cystoscopic procedure. For the cystoscopy, report 52000 (Cystourethroscopy [separate procedure]).

In this case, you should also use different diagnoses for the E/M service and the cystoscopy. For the diagnosis of BPH, report 600.01 (Benign prostate hyperplasia, with urinary retention). You should link ICD-9 Code 599.7 (Hematuria) to the cystoscopic procedure. Decision for Surgery Supports Modifier 57 You should append modifier 57 (Decision for surgery) to an E/M code to indicate that an appointment resulted in the urologist’s recommendation for surgery. Basically, this modifier clarifies that the E/M service provided on the day of or [...]