Urology Coding Alert

Question: When caring for a patient with a non-palpable testis in an office exam, I plan for operative repair. The first step of the operation is an evaluation under anesthesia (EUA). Based on these findings, I may perform a standard inguinal orchiopexy, transfrontal orchiectomy with contralateral orchiopexy or diagnostic laparoscopy for evaluation of an intra-abdominal testis. I have met resistance from insurance companies on several fronts. Is there a way to bill for the EUA, as it has a significant effect on my operative approach? Now that there is a code for laparoscopic orchiopexy, is the diagnostic laparoscopy bundled with this?

Missouri Subscriber

Answer: You cannot bill for an EUA if it is a nonsurgical exam. The diagnostic laparoscopic EUA may be reported separately when it is performed prior to an open procedure and when it is medically necessary to determine the physicians next course of action. To communicate this information to the payer, modifier -59 (distinct procedural service) is attached to the diagnostic laparoscopy code.

The use of the modifier does not guarantee payment. Individual payers may not recognize the modifier, may not allow payment even if it is recognized, or may not agree that the service is distinct in accordance with their processing guidelines. Per CPT guidelines, surgical laparoscopy includes a diagnostic laparoscopy. Using the laparoscopic orchiopexy as an example, diagnostic laparoscopy (e.g., 49320) is included in 54692 (laparoscopy, surgical; orchiopexy for intra-abdominal testis) and is not reported separately.

Answers to You Be the Coder and Reader Questions provided by: Ray Painter, MD, president of PRS, a coding and reimbursement consulting firm in Denver; Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding, compliance and reimbursement consulting company in Denver; Laura Siniscalchi, CPC, RHIA, CCS, CCS-P, education coordinator for coding at Beth Israel Deaconess Medical Center in Boston; and Scott Roberson, CPC, CPC-H, APC, Senior Coding Consultant at Intermountain Health Care, a multi-specialty practice in Salt Lake City.