Revenue Cycle Insider

Find out if you’re using pre- and post-op modifiers correctly.

Accurate coding in urology is more than a back-office administrative function; it is a linchpin of financial stability, regulatory compliance, and quality patient care. Urology practices routinely manage complex diagnostic procedures, in-office surgeries, imaging, pathology, and chronic disease management. This breadth of services increases the likelihood of coding errors, particularly when documentation, payer policies, and evolving coding rules intersect.

For urology coding professionals, even small mistakes can lead to denied claims, compliance risks, lost revenue, and distorted clinical data. Understanding common errors — and their downstream consequences — can help practices strengthen processes and safeguard both reimbursement and patient care.

Protect Your Practice and Your Patients

Coding inaccuracies in urology have consequences that extend beyond reimbursement delays, and even beyond your practice. Your practice could experience:

• Financial loss and cash flow disruption;
• Audits, penalties, or fraud allegations; or
• Increased administrative burden as staff deals with appeals.

Additionally, your patients are at risk of:

• Denied coverage for medically necessary treatment;
• Delays in treatment approvals;
• Inaccurate records affecting future care decisions; and
• Disruption in continuity of care for chronic conditions like benign prostatic hyperplasia (BPH), urinary incontinence, or prostate cancer.

While every specialty faces coding challenges, there are several errors that appear frequently in urology practices. Here’s a look at some of those urology-specific errors and how to avoid them.

Watch Those Modifiers

Modifier misuse is one of the most common — and risky — errors in urology coding. Common pitfalls include:

• Improper use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of a procedure or other service)
• Inappropriate application of modifier 59 (Distinct procedural service) or X{EPSU} modifiers indicating separate encounters, structures, practitioners, or unusual non-overlapping services to unbundle services
• Incorrect use of modifier 26 (Professional component) or TC (Technical component …) on diagnostic tests
• Failure to append modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period), 57 (Decision for surgery), or 79 (Unrelated procedure or service by same physician or other qualified health care professional during postoperative period) during pre- and postoperative periods when warranted

Example: Billing an evaluation and management (E/M) visit with modifier 25 on the same day as a cystoscopy without clearly documented separate, significant evaluation can lead to denials or audit exposure. Make sure that your documentation clearly supports medical necessity and the distinct nature of the services when using modifiers.

Understand the Global Surgical Packages

Urology includes many procedures with 0-, 10-, and 90-day global periods, in which any further services your urologist performs might be considered to be a necessary part of the original service, and thus not separately reimbursable. Coders frequently make errors in determining what services are included in the global package, leading to CPT^® stating that the global period for surgeries and procedures always includes:

• Subsequent to the decision for surgery (procedure), one related E/M encounter on the date immediately prior to, or on the date of, the procedure; and
• Immediate postoperative (post-procedure) care, including talking with the family and other physicians.

If the service the physician provides is truly unrelated to a procedure’s global package, append modifier 24 for preoperative care and modifier 79 for postoperative care.

Example: A patient has a prostatectomy (55840 [Prostatectomy, retropubic radical, with or without nerve sparing]), which is a procedure with a 90-day surgical package. Two weeks later, the patient has a kidney stone removed (52352 [Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)]). Append modifier 79 to 52352 to protect payment.

Make Sure Documentation Supports Medical Necessity

Many urology procedures — such as urodynamic testing, prostate biopsy, or imaging studies — require detailed documentation to establish medical necessity. Without documentation, services that are appropriate may nevertheless be denied. Common documentation gaps are:

• Missing symptom descriptions
• Lack of failed conservative treatment history
• Incomplete indication for diagnostic testing
• Insufficient detail to support high-level E/M services

Do this: Educate providers on documentation elements required for both CPT^® and ICD-10-CM coding specificity.

Beware the Bundles

Urology procedures often involve components that are bundled under National Correct Coding Initiative (NCCI) edits. Improperly unbundling the procedures (for example, reporting them as separate procedures) can lead to overpayments and audit exposure. Common pitfalls include:

• Billing catheter insertion separately when it is integral to a procedure
• Unbundling cystoscopy from related surgical services
• Billing imaging guidance separately when it is included in the primary procedure

Additionally, many urology practices provide in-office ultrasound, X-ray, or pathology services. Common mistakes in reporting these ancillary services include:

• Failing to distinguish between professional and technical components with modifiers 26 and TC
• Billing for imaging without proper supervision documentation
• Incorrect place-of-service coding
• Not verifying payer-specific coverage requirements

These services can represent substantial revenue, but they are also heavily scrutinized.

Jerry Salley, BA, MFA, Contributing Writer