Urology Documentation requirements:

• Proper documentation of office procedures is the foundation of good clinical care, licensure in most states, risk management, compliant coding, and optimal reimbursement.
• As per 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.

Minor Surgeries and Endoscopies: 

• Visits by the same physician on the same day as a minor surgery or endoscopy are included in the Payment for the procedure, unless a significant, separately identifiable service is also performed.
• For example, a visit on the same day could be properly billed in addition to suturing scalp would if a full neurological examination is made for a patient with head trauma.
• Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status

Multiple Procedures – Urology:

• 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.
• 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).

GLOBAL PERIOD:

• 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.

NCCI Edits for Urology Procedures:

• 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).
• NCCI code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services
• Most commercial insurers include NCCI edits, and the CMS updates this list quarterly.

Modifiers 25 in Urology:

Correct use of 25 modifiers includes

• Two co‐existing unrelated problems (with separate diagnoses)
• Problem prompts E/M service and a procedure (may use the same diagnosis)
• Same day counselling after surgery

Modifier 59:

Bill Modifier 59 only if the following criteria met

Different session, Different patient encounter, Different procedure, Different surgical incisions, different sites / separate organs, Separate sites in a single organ, Different organ system

Medicare has stated that modifier 59 is appropriate on a bundled procedure for payment. If procedures are performed for lesions anatomically separate from one another in the same organ.