Urology Coding Alert

Reader Questions:

Use Caution on Post-Procedure Cath Removal Coding

Question: The NCCI Policy Manual, Chapter XIII, Category III Codes makes the following reference to the global period XXX: “Procedures with a global surgery indicator of ‘XXX’ are not covered by these rules. Many of these ‘XXX’ procedures are performed by physicians and have inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed. This work shall not be reported as a separate E&M code.” What does this mean? More specifically, can a physician bill for a follow-up evaluation and management (E/M) encounter a day or two after surgery for the same patient for the same diagnosis? Here is the specific case I am wondering about: The procedure is an aquablation procedure, resection of the prostate gland due to benign prostatic hyperplasia (0421T). For example, the patient undergoes the aquablation procedure in the outpatient hospital setting and is catheterized after the procedure. That same patient then presents at our office within the next day or two for catheter removal. Can we bill Medicare an E/M code for this follow-up visit if there are no extraordinary circumstances?

North Carolina Subscriber

Answer: You will need to check with your payer about their policy for reporting E/M codes during the postoperative period of a surgery that does not have a global period. Payers will likely consider a catheter removal after an aquablation an inherent service and the E/M service for solely that purpose would not be separately reportable even though 0421T (Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)) has an XXX global period, which means “The global concept does not apply to the code.”

Remember: The assigned global period is different from the global surgery concept. According to CPT®, the surgical package includes the following:

  • The surgical procedure
  • Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia
  • One related E/M encounter (including history and physical) that occurs after the decision for surgery has been made and is either on the date immediately prior to the procedure or on the actual date of the procedure
  • Immediate postoperative care, including dictating operative notes and talking with the family and other physicians
  • Writing orders
  • Evaluating the patient in the post-anesthesia recovery area
  • Typical postoperative follow-up care

CPT® guidelines state “typical postoperative follow-up care” includes “only that care which is usually a part of the surgical service. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported.” Therefore, from a CPT® coding perspective, since catheter removal would be typical postoperative care, you should not separately report the service.