Urology Coding Alert

An ultrasound often but not always should be billed with an office visit. Only by knowing the guidelines for when you can bill for an office visit can you get extra reimbursement, as well as avoid possible fraud charges for those times when billing an office visit would not be warranted.

When the diagnosis is the same for the ultrasound and the visit, submit a claim for both. Not doing so is cutting your practice out of proper reimbursement, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding, compliance, and reimbursement consulting firm based in Denver, Colo.

When to Use Modifier -25

For example, a 50-year-old patient has erectile dysfunction, but he is on Viagra. He comes in for a regularly scheduled visit, and upon doing a digital rectal exam (DRE), the urologist finds a hardening of the prostate. The physician knows from a previous workup that the PSA (prostate-specific antigen) is fine, so no biopsy is necessary. But he wants to do a transrectal ultrasound of the prostate. How would this visit be coded?

Some coders recommend using modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). You would code the office visit, which probably would be 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires a problem focused history and examination, and straightforward medical decision-making) with a modifier -25, says Laurie Slater, surgical coordinator for Urology Associates, a four-urologist practice in Wakefield, R.I. It would have to be a separately identified service. Then, you would code the ultrasound 76872 (echography, transrectal).

Even though CPT specifically states that you do not need a separate diagnosis when using modifier -25, for practical reimbursement purposes, says Slater, you do. In order to get paid, you want to show why the office visit is different from the procedure and a different diagnosis is the best way to do that. The recommended diagnoses are 607.84 (impotence of organic origin) for the office visit and 222.2 (benign neoplasm of male genital organs; prostate) on the ultrasound.

Tip: If you dont have any pathology results indicating a neoplasm, code 600 (hyperplasia of prostate), which is exclusive of benign neoplasm of prostate. Do not code the neoplasm unless a biopsy has been done.

How to Bill With No Modifier

With Medicare, you do not need to use modifier -25 on an office visit thats done with a radiological procedure, explains Page.

For instance, a 50-year-old patient comes in complaining of a slow urine stream. The urologist has not seen the patient for months. He also has a slightly [...]