Urology Coding Alert

Question: I received a denial from one of our carriers that I need help with. I coded the following: 52281 -- Insurance paid on this 76872-26 -- Insurance paid on this 76942-26 -- Insurance paid on this 55700-51 -- Insurance paid on this 51702 -- Insurance bundled this with 52281 and did not pay on 51702 51798 -- Insurance bundled this with 76872 and did not pay on 51798. The carrier goes by Medicare guidelines. Can I add a modifier to 51798 to get this one paid? South Dakota Subscriber
Answer: Most carriers now consider that when a urologist performs a sonographic post-void residual (PVR) volume determination (51798, Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) at the same time he performs a transrectal ultrasound (TRUS, 76872, Ultrasound, transrectal), you should report only one code. Carriers usually do not allow you to unbundle these procedures when the physician performs them both during the same encounter. Bill only for the higher-paying code (76872). Good news: Despite the bundling, if your urologist does the PVR volume determination and TRUS at different times or during separate encounters on the same day, you should report both. Append modifier 59 (Distinct procedural service) to 51798 to break the bundling edit and ensure payment. Caution: Carriers won't pay for 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]), regardless of modifiers, because the Correct Coding Initiative bundles the procedure with 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female), and you cannot unbundle or bypass this edit with any modifier. -- Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis.