This article summarizes current best practices for documenting, coding, and billing common office-based urologic procedures. Topics covered include general principles, basic and advanced urologic coding, creation of medical records that support compliant coding practices, bundled codes and unbundling, global periods, modifiers for procedure codes, when to bill for evaluation and management services during the same visit, coding for supplies, and laboratory and radiology procedures pertinent to urology practice. Detailed information is included for the most common urology office procedures, and suggested resources and references are provided. This information is of value to physicians, office managers, and their coding staff.
Key points
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The American Medical Association is the steward of Current Procedural Terminology (CPT), and the Centers for Medicare and Medicaid Services (CMS) often implements that terminology in rules and regulations that are followed by most insurance payers.
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CPT codes are highly specific, and there is a code or set of codes to fit all office urology procedures and common scenarios.
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Many resources are available to assist in complex coding scenarios.
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Coding for urologic office procedures is founded in proper documentation in the medical record.
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Urologic office procedures often involve expensive drugs or disposables, and recovery of acquisition costs depends on a detailed understanding of coding rules and nuances.
Introduction and purpose
Typical urologists today generate a significant portion of practice revenue performing procedures in the office, and a detailed knowledge of documentation and coding guidelines is necessary to insure appropriate, compliant, and optimal reimbursement. Several recent trends have highlighted the importance of coding, billing, and collecting payment correctly for office-based procedures. Diagnostic and therapeutic procedures, once commonly requiring facility-based anesthesia services, can now be performed in a urologist’s office. The stewards of procedural terminology have introduced more codes with more specificity to replace general codes in the urinary and male genital sections and, in some cases, deleted once commonly used codes. Advances in technology have introduced new office-based procedures into the armamentarium of urologists—for example, in the treatment of benign prostatic hypertrophy—demanding new codes. Worker salaries and other practice expenses for urologists continue to rise, while allowable charges for procedures have remained flat or even decreased. Employers and insurance companies are asking patients to shoulder more responsibility for health care expenses; patients in turn are demanding more transparency in their bills. The emergence of value-based payment systems and the passage of health care reform legislation are predicted to result in savings primarily by reducing payments to hospitals and surgical specialists. Commercial payers are attempting to control rising costs by managing utilization of high cost procedures, thereby increasing the number of office-based procedures that require preauthorization. Finally, federal agencies have signaled their interest in recovering overpayments made to providers for high-volume, high-cost procedures with an emphasis on medical necessity and appropriate documentation. In this complex and changing landscape, it is imperative that urologists document and bill correctly for office procedures.
This article first reviews some general principles of proper documentation, coding, and getting paid for procedures performed in a urologist’s office. Then, specific coding and billing issues for each of the most common diagnostic and therapeutic procedures are examined. By the end of this article, readers should have a tool for their practice that should optimize reimbursement and ensure standard and compliant documentation and coding.
General principles
Definition of a Procedure
Although many factors may determine the setting in which a procedure is performed, for the purposes of this article, office-based urologic procedures are defined as those urinary or genital tract procedures that do not require services only available in an operating room and that are commonly performed in a urologic office setting in the United States. The procedure may be diagnostic or therapeutic in nature, may be invasive or noninvasive, and usually includes the professional service to perform the procedure, any same-day evaluation and management (E&M) services related to the procedure, and the supplies necessary to conduct the procedure. Most office-based urologic procedure codes and their descriptions can be located in the surgery section of the American Medical Association CPT manual, urinary system subsection (50010-53899) or male genital subsection (54000-55899).
Documentation
Proper documentation of office procedures is at the foundation of good clinical care, licensure in most states, risk management, compliant coding, and optimal reimbursement. All urologists should be familiar with an axiom used by utilization review companies, payers, state and federal regulators, and malpractice experts and quoted in the American Medical Association CPT manual: “if something is not documented in the medical record, then the procedure was not performed and therefore is not subject to reimbursement.” The components of procedural documentation are standard, often routine, and lend themselves well to paper forms or electronic templates. The indication for the procedure should be clearly listed to support medical necessity. The place of service (office and examination room) should be clearly specified, not simply inferred from the name of a provider and a date. The normal and abnormal findings of the procedure, and any complications, should be described separately from the procedure itself because they are always unique to a patient and procedure. The procedure note itself should be descriptive enough to support the relevant procedure code and specific enough to support a standard of care but not contain unnecessary detail that obscures the important content. Finally, the procedure note should be separate and clearly distinguishable from documentation of any other services performed during the same visit.
Documenting common procedures presents an opportunity for efficiency by designing and using paper forms or electronic templates, but a careful balance must be struck between benefit and risk. With the adoption of electronic health records in group practices, the person who designs the templates is often not the only person who uses the templates; furthermore, many electronic medical records do not easily allow users to view the data entry screen and the output screen at the same time. Finally, the ability to “copy forward” procedural notes, such as surveillance cystoscopy for bladder cancer, can result in “cloned notes” and unintentionally perpetuate documentation that is not appropriate. These factors can introduce significant risk of inaccurate documentation that can be mitigated with careful template design. For example, a male cystoscopy template might contain default content for preparation of the genitals, insertion of the scope, and systematic inspection of the bladder—but should not contain text, settings, or other content, such as “all findings were normal,” that could be inserted inappropriately and inadvertently. A well-designed template should allow users to be efficient, thorough, and accurate in the creation of a compliant yet readable note. The ideal procedure template should also make clear the contents of the note output to minimize inadvertent documentation.
Coding for Office-Based Procedures
Office procedures are described and classified in CPT 5-digit codes, a system copyrighted by the American Medical Association, mandated by federal law for government insurance programs, and accepted as the standard nomenclature by commercial insurance payers. The most relevant codes in the CPT manual for office-based urology procedures are in the surgery subsections of urinary system (50010-53899) and male genital system (5400055899). The CPT codes are revised once a year, and it is essential that the urology practice keep current with additions, deletions, and changes to the CPT manual. Causes for claim denial include use of an outdated code, failure to use a new code, reporting the wrong code, and use of a nonspecific unlisted code when a specific one exists. Whenever possible, the provider or staff member performing the office procedure should be the same person who assigns or approves the code submitted for billing. Urologic procedures performed in an office setting should always be billed with the place of service code 11 (office facility).
Multiple procedures
Although CPT codes for most office-based urology procedures are specific and inclusive, some office procedures (transrectal ultrasound–guided prostate biopsy, for example) require more than 1 CPT code for compliant coding and optimal reimbursement. The rules governing which codes can be paired with other codes are administered by the CMS and are called the National Correct Coding Initiative (NCCI) (also known as CCI). This system was implemented in 1996 by the CMS “to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. NCCI code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.” For example, the NCCI edits permit submitting a prostate biopsy (55700) and a transrectal ultrasound (76872) but never allow the submission of cystoscopy (52000) and complex catheterization (51703) on the same date of service. Most commercial insurers include NCCI edits, and the CMS updates this list quarterly.
When multiple codes are necessary and appropriate, it is best practice to report the procedure with the highest fee first, the additional procedures on separate lines of the claim form with a -51 modifier attached, and to submit full fees for each procedure. Most insurance payers reduce the reimbursement of the second and additional procedures by at least 50%. The practice of itemizing multiple CPT codes when only 1 code is “needed” is referred to as “unbundling,” and systematic unbundling may invite the scrutiny of auditors and regulators. In some circumstances, it is appropriate to report multiple codes considered bundled under current CCI data sets—a modifier may be used when conditions warrant separate reporting (decision for surgery, left or right laterality for example). Later in this article, the best practice for coding common procedures that require more than 1 CPT code is discussed.
Global period
In order to process claims quickly and accurately, most payers have developed specific definitions for a global surgical package, including time frames (the global period) during which other professional services are considered included in the payment of the procedure. Most payers follow the definition of the global surgical package developed by the CMS, and most procedural CPT codes on the Medicare fee schedule are associated with a global period of 0, 10, or 90 days. The global surgical package specifically includes the procedure itself, all services that are a “usual and necessary” part of the procedure, local anesthesia, the treatment of any minor complications related to the procedure, E&M services performed on the day of the procedure (exceptions discussed later), and, in cases of 90-day global packages services, the day of and day prior to the procedure. Diagnostic urology procedures performed in the office generally have a 0-day global period, but some therapeutic procedures—including vasectomy—have a 90-day global period. Urologists should also understand when it is permissible to bill for an office procedure when it is performed in the global period of another earlier procedure, such as cystoscopy and stent removal after extracorporeal shock wave lithotripsy . Submitting claims for services normally included during the global period is considered unbundling. The global period for each CPT code is generally listed on the insurance company fee schedule and can also be found at the CMS Web site.
Supplies
CPT and Healthcare Common Procedure Coding System (HCPCS) level II codes also form the basis of the resource-based relative value system used by the CMS and most commercial payers to set fees. Most codes contain component relative value units that consider physician work, practice expense, and malpractice cost for that particular procedure. For this reason, the cost of supplies and equipment used during an office-based procedure are usually factored into the fee and are generally not billed or reimbursed separately.
Modifiers
A urologist’s coding staff should be familiar with CPT code modifiers. When used appropriately, modifiers may increase reimbursement and, when used inappropriately, may result in claim denial or payer audits. Although a comprehensive discussion of modifiers is beyond the scope of this article, some examples of modifiers that might be appropriate for some office-based procedures are found in Table 1 .
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