Mark Painter is CEO of PRS Urology SC in Denver.

Mark Painter

I am wondering if code 38571-52 would be appropriate in the following scenario at the time of a robot-assisted laparoscopic prostatectomy:Patient is noted to have a paucity of lymph node tissue overlying the left iliac vein and obturator nerve. Right-sided pelvic lymph node dissection was then performed with the margins being the pelvic sidewall, obturator nerve, and iliac vein. Proximal and distal ends of the lymph node packets were ligated with hemo lock clips and transected with electrocautery. Specimen was then sent out as right pelvic/obturators lymph node package. This was performed at the time of a robot-assisted laparoscopic prostatectomy.Or, would we need to use unlisted code 38589 and compare it to 38562 approximately? And do you have another comparable code for reimbursement comparison if I need to use unlisted code 38589 and code 38562 is not close enough?

Common Procedural Terminology (CPT) code 38571 describes 

Laparoscopy, surgical: with bilateral total pelvic lymphadenectomy

Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic.

 The work of performing CPT code 38571 includes the removal of the total lymph node packet from both sides of the pelvis. In the case described above, a complete lymph node packet was removed from 1 side of the pelvis only. When reviewing the 2 options you describe, it would be most appropriate to bill CPT code 38571 and to append modifier –52 

to the code. That describes the service performed more accurately than a limited pelvic lymph node dissection, as it describes the completeness of the lymph node dissection and approach 

(laparoscopic), albeit just the 1 side. The option of the unlisted laparoscopic code 38589, as you noted, is also a valid choice, referencing the reduced value of 38571. Either way the service is reported, the payer should require documentation be submitted for review prior to payment, and the use of the –52 on the 38571 will provide more appropriate guidance for reimbursement processing.

 is compliance officer and medical director of coding and reimbursement, United Urology Group and Chesapeake Urology, Towson, Maryland. 

 is CEO of PRS Urology SC in Denver, Colorado.

Send coding and reimbursement questions to Rubenstein and Painter c/o

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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"Either way the service is reported, the payer should require documentation be submitted for review prior to payment, and the use of the –52 on the 38571 will provide more appropriate guidance for reimbursement processing," write Jonathan Rubenstein, MD, and Mark Painter.

Why CPT 38571 plus modifier 52 is recommended in this RALP case

When my provider is doing urodynamic studies, they are documenting “Post Void Residual Urine: Residual urine is 15 ml measured by urethral catheterization.” The code that has been sent over is 51798; however, that states by “ultrasound, non-imaging.” I am fairly new to this coding and wondering if another code better supports the postvoid residual [PVR] urine in this scenario or if nothing is billed for this type of case. I believe the 51798 is not supported here.

First of all, welcome to this coding thing and glad to have you on board. We always appreciate excellent questions, especially those that are asked with insight. We always encourage people to ask advice, especially when something doesn’t pass the “sniff test.”

Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging

. This means that an external device, usually a hand-held or portable machine that will give an estimate of the urine remaining in the bladder, is used to obtain the necessary data. (And also note that even if an 

imaging device was used to capture the residual, if the goal of the test is to check for bladder urine volume, CPT code 51798 should be used as opposed to an ultrasound code.)

When placing a catheter to check a residual urine volume, whether it be performed by a straight catheter or a urodynamics catheter, CPT 51701 

Insertion of non-indwelling bladder catheter (eg straight catheterization for residual urine)

 is the appropriate code to use. However, in the case of performing a concomitant urodynamics study, CPT 51701 is bundled to the urodynamics codes and cannot be billed separately. Determining the PVR as part of a urodynamics test is part of the test itself and included in the payment already.

"Determining the PVR as part of a urodynamics test is part of the test itself and included in the payment already," write Jonathan Rubenstein, MD, and Mark Painter.

Is 51798 appropriate for billing postvoid residual measured by catheterization?

I have heard you mention in one of your presentations that you need to make sure you document that you have used data in your medical decision-making (MDM) to count the data as part of MDM. What does this mean?

MDM is intended to measure the relative mental-work effort required to manage a patient complaint. Documentation of the data reviewed/ordered and the reason the information is required not only reflect the mental work needed for a problem but support the medical necessity of the test. Unnecessary tests have been a target of many chart reviews. Poor documentation of the reason and use of these tests has resulted in several large take-backs for a number of urologists over the past few years for both the test payment and a change in the evaluation and management (E/M) code reimbursed.

We have addressed documentation of data as part of MDM because the appropriate use of data as part of MDM was a focus of several payer chart reviews prior to the adoption of the new E/M guidelines. As such, the question is a good one and applicable to both office-visit codes under the new guidelines and the other E/M 

To protect your practice from take-backs and support the level of service, we recommend the following:

• For each test/image/diagnostic service ordered, include a clear reason/diagnosis supported by the patient’s presentation for the visit.

• For each test/image/diagnostic service result reviewed, list the relevant information/result in association with a treatment or follow-up next step.

This can be as simple as listing the orders such as Cysto/Cytology/CT for Gross Hematuria standard work-up or can be supported in more detail to include rule-out diagnosis codes in addition to the diagnosis driving the orders.

For results reviewed, it is not enough to simply list results in the medical record. However, you can be concise in referencing the data in conjunction with the next step—for example, postvoid residual 35 mL continue current medication.

In short, good documentation is not necessarily measured in the number or words included in the medical record. However, it does require that the chart note can be followed by other medical professionals for continuity of care. Unfortunately, it should also demonstrate to the chart reviewer, typically not a medical professional, that the information reviewed/ordered was obviously related and required to address the patient’s medical needs.

Include clear reason/diagnosis for each test, image, and diagnostic service ordered.

How to incorporate data in your medical decision-making

We decided to head in a different direction with this month’s column. We have done our best in many of our articles to impress upon the reader the importance of accurate and complete documentation, as the medical record serves as both the key to appropriate ongoing care for your patient and proof of services provided. Documentation is important to communicate what you are thinking, what you have done, and what you are planning in relation to each patient’s treatment, and therefore it is the key to being reimbursed for the work provided. Unfortunately, sometimes even thorough and complete documentation does not result in payment by an insurance company for quality medical care.

What insurance companies decide is or is not covered does not always make sense. Keeping up with coverage decisions for all your payers requires a coordinated effort by your entire staff. An efficient urology office will invest in this process. It is frustrating and takes time to develop and maintain, but once in place it will pay immediate dividends. The goal is to know if you are going to be paid before you provide the service and who is responsible for what portion of the amount owed to the practice.

You can do everything as planned and still run into frustrating delays and roadblocks and even the unexpected outright denial. These roadblocks, delays, speed bumps, and administrative/technicality denials seem to be on the rise. Even with well-documented charts, it may feel that insurers aren’t being true to their word of coverage or don’t have enough trust that the provider is using their skills and judgment for the best possible patient outcomes.

In addition, medical record requests prior to payment are all too commonplace, leading to frustrating delays in patient care. We also have seen an increase in reviews for services already paid, which further increases the expense of running a practice. Often, there is seemingly little method to this madness of requests. The requests that do not fit a clear pattern are what we would classify as probe audits.

Include supporting documentation with records

Regardless of which type of request you receive, make sure you send all relevant portions of the medical record requested. We have seen many medical records sent for review that support an evaluation and management service or procedure but are missing lab or imaging service reports that also were billed. Before sending in medical records, ensure that each service that was reported has the supporting documentation included. If the documentation cannot be found, explain the circumstance and, if appropriate, addend the medical record, but do so in a manner that clearly acknowledges the addendum.

Certainly, this is nothing like it used to be. There has never been a time when so much scrutiny has been placed on providers and practices. The obvious primary driver of medical record requests is money. The payers monitor billing patterns of providers and groups and will select notes for review based on billing patterns that do not conform to other urology groups. If your group demonstrates in a review that you are documenting well and understand the rules, you are less likely to be investigated further. If they find a problem that they were looking for based on your coding patterns (eg, uroflow test on a higher percentage of patients than average) or based on a random chart audit, you are likely to receive a request for repayment.

Although many payers will limit the takeback to the records reviewed with problems that have been identified, others will extrapolate the problem as a percentage of all claims with the same coding pattern and request a settlement in a larger amount. It is important to scrutinize any payers’ findings in these chart reviews.

We have been involved in a number of chart reviews. Most reviewers in these types of audits do not understand urology, and we have been able to get many “mistakes” overturned. To do so, it is extremely important to have the physician involved in the process. Although a coder/auditor should make the first pass in analyzing the payer audit, it is important to find out physician intent and prepare a response understood and signed by the physician. If your chart review agrees with the payer findings, you should admit the mistake and communicate any corrective actions that you are going to take to stop the practice. If these communications are verbal, record the conversations, if possible, or summarize the communication in a letter or email back to the payer. We do not recommend simply paying the requested takeback in any case. Respond to each finding, even if you agree with them and pay in full.

The record requests for individual services based either on the type of service provided or a seemingly random record request either prior to or after payment are similar. The process of gathering and submitting the medical record should not change; submit the entire record and check for support of all services reported. We recommend that you review and check with physicians regarding documentation only if needed instead of holding records for physician review. What you learn from these chart reviews will need to be communicated to the office as appropriate. If, for example, you find that a payer has implemented a policy that requires a specific test or treatment failure prior to treatment with a given surgery, make sure that the clinical records include the required test or treatment failure and that the surgical scheduler, physician, advanced practice provider, and nursing staff understand and document the requirements for each test. Stop the hemorrhage before it starts.

If your billing staff is monitoring payer websites and carefully reviewing billing requirements for any new technology, you will be able to avoid some of these takebacks but likely will not avoid medical record requests; at this point, you instead need to plan for this administrative delay in payment.

We have noticed an additional frustration in the medical record review process. Not all payers fall into this category. But we have received a growing number of reports of medical records that are submitted to the payer, who then sends the medical record to a review company that makes a recommendation back to payer. The payer then has the choice of how to act on the recommendation provided. This 2-tier process has created numerous problems. The most annoying is the number of records that are “lost” by the payer or the review company. We have seen some cases where medical records were submitted and acknowledged as received but later not found. Aside from being ridiculous, this surely violates some law or rule. But to date, the legal cost to prove this is difficult to justify. Perhaps someday soon, this payer practice will result in a class-action lawsuit.

In lieu of a class-action lawsuit, what can you do? Obviously, if the answer were easy it would have been implemented. At this point, it looks as though the problem will require an approach that is bigger than a single practice can handle, aside from accurate documentation and arguing cases aggressively, which can serve as a deterrent. Group action will likely require legal and contract changes that can be accomplished through state legislation. Because states regulate insurance, it is up to each state to introduce appropriate legislation to prohibit these practices. Your state medical society, urology state chapter, LUGPA, the American Association of Clinical Urologists, and the American Urological Association all have active lobbying groups that may be able to assist.

As this is not a urology-specific problem, coordinating with the state medical society is imperative. Look to other states to see what they have successfully implemented. Texas and other states have passed laws that restrict medical records request under monetary penalties if the record is requested prior to payment. If you are able get regulations passed in your state, the next step is to know your rights so you can enforce these new laws. Or, hopefully, if providers do such an excellent job with accurate billing and documentation that audits become futile and cost prohibitive for insurers, they will stop playing games with our charts. We don’t want this issue to tear us apart. But we do not see this problem going away without a groundswell of support and complaints. It is time to get active.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Physician involvement in responses to payer audits is crucial.

Mark Painter

Articles

Why CPT 38571 plus modifier 52 is recommended in this RALP case

Is 51798 appropriate for billing postvoid residual measured by catheterization?

How to incorporate data in your medical decision-making

What can you do about rising medical record review requests?