Mark Painter is CEO of PRS Urology SC in Denver.

Mark Painter

My provider asked me how to code a prolonged audio-only evaluation and management (E/M) visit in which they spent 75 minutes with the patient by phone. Since the visit was performed with audio only, we are aware that standard outpatient (face-to-face) E/M codes 99212 through 99215 would not be used, and we know that CPT code 99443 is for a phone visit of 21 to 30 minutes. Is there an add-on code that can be used in a circumstance such as this to report the additional time over the 30-minute mark? Thank you.

You are correct that audio-only (telephone) E/M services would not use “Office or Other Outpatient Services” (CPT codes 99202-99205 or 99211-99215), but rather are reported using CPT codes 99441-99443 based upon the amount of time of medical discussion (5 to 10 minutes, 11 to 20 minutes, and 21 to 30 minutes for CPT codes 99441, 99442, and 99443 respectively). (Note: for the purposes of this question, we are excluding the Centers for Medicare & Medicaid Services Healthcare Common Procedural Coding System [HCPCS] codes G2012 “virtual check-in, 5 to 10 minutes of medical discussion” and G2252 for “11 to 20 minutes” of medical discussion). Note also that CPT codes 99441-99443 have limitations for reporting and can be submitted only if they are “not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment” because otherwise the encounter is considered part of the previous E/M service or preservice work of the subsequent visit. Again, for the purposes of this question, we are assuming that this interaction is reportable as it does not meet the exclusions.

As for the case described of a 75-minute audio-only E/M visit there has been no specific coding guidance provided by CPT. When the audio-only CPT codes were created, it was likely not anticipated that there would be occurrences of such prolonged audio-only E/M visits. We then need to look at other codes that can be used in situations such as this and have come up with 2 options: Prolonged service codes (such as CPT codes 99354 and 99355, which describe “Prolonged service with Direct Patient Contact”) and add-on CPT code 99417, “additional 15 minutes”. 

CPT codes 99354 and 99355 are described as used for additional time of services with direct patient contact except with Office or Other Outpatient Services (CPT codes 99201-99205 or 99212-99215). Since audio-only codes are not these types of services, they are not specifically excluded from being added to audio-only E/M services. These codes can be used when the extra time exceeds 50% of the listed time, which means CPT code 99354 (first hours additional time) can be reported only when 30 additional minutes are spent.

CPT code 99417 is an add-on code to report prolonged Office or Other Outpatient E/M services above the maximum time if reporting using time. The advantage of this code is that it can be billed in 15-minute increments for each additional 15 minutes of time and audio-only E/M codes are in spirit being used as Office or Other Outpatient services. Unfortunately, it is unclear whether it will be accepted if added on to 99441-99443.

Therefore, although there is no specific correct answer to this question as there is no specific guidance for how to report such prolonged audio-only visits, one could try reporting either CPT codes 99443 plus 99354, or CPT codes 99443 plus 99417 x 3. There is a compelling argument for each, but ultimately the actual payment may be at the whim of the insurer.

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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"As for the case described of a 75-minute audio-only E/M visit there has been no specific coding guidance provided by CPT," write Jonathan Rubenstein, MD, and Mark Painter.

How do you bill for a 75-minute audio-only E/M visit?

I have an ultrasound machine that provides images. Can I use 76856 for a post-void residual (PVR) instead of code 51798? Also, we normally bill code 76705 for kidney ultrasounds and we use code 76857 for ultrasound of the bladder. What is the best way to report an encounter when both the kidney and bladder are imaged?

For appropriate billing and coding, there are 2 important issues to be satisfied: medical necessity and documentation supporting the performance of the procedure.

Regarding your first question, obtaining an image is secondary to the reason for the service based on patient condition and diagnostic needs. Remember that most payers have different rules for screening services than they have for services directed toward an existing problem. Medical necessity for a bladder scan will need to be clearly supported with chief complaint. The documentation will also need to describe the service provided and an interpretation of the image separately documented. Merely obtaining images does not satisfy the requirements to report CPT 76856 if the intent of the procedure was to obtain a PVR.CPT code 51798 should be reported to obtain a PVR whether using imaging or non-imaging modality.

For several questionable cases we have reviewed, the need for a PVR is supported by the chief complaint and the procedure note has included a full bladder scan image including pre- and post- void imaging and a full and separate report interpretation. In these cases, based on diagnosis restrictions and the chief complaint, we have recommended reporting code 51798.

The second question has been answered previously by the American Urological Association (AUA):

“You cannot bill for both a 76705 Ultrasound abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) and a 76857 Ultrasound, pelvic (nonobstetric), real time with image documentation, limited or follow-up (eg, for follicles) when each of these organs is evaluated. CPT code 76770 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation, complete should be billed if the clinical history suggests urinary tract pathology, and evaluation of both kidneys & bladder.”

We agree with the AUA for coding in this regard as it follows CPT nomenclature and coding guidance.

We have heard there are some payers that will not allow for billing of code 76770 for this service and have requested the codes for kidney and bladder ultrasound to be reported separately when supported. If you have a payer requesting billing of services that do not agree with CPT nomenclature requirements, we strongly recommend that you obtain these instructions in writing.

1. Imaging radiological procedures. American Urological Association. Accessed June 2, 2022. https://bit.ly/3tcuGm8

"For appropriate billing and coding, there are 2 important issues to be satisfied: medical necessity and documentation supporting the performance of the procedure," write Jonathan Rubenstein, MD, and Mark Painter.

What is the best way to report an encounter when both the kidney and bladder are imaged?

I’m looking for some guidance on a couple of stone case scenarios. Both scenarios have to do with shock wave lithotripsy (SWL) and ureteroscopy with laser lithotripsy being performed on the same side during the same operative session.

First scenario: A patient has stones in both the kidney and ureter on the right side. The physician has both ureteroscopy with laser equipment and an SWL machine available. The urologist performs a ureteroscopy with lithotripsy of both the ureter and kidney stones and places a stent, completely lasering the ureter stone but incompletely lasering the kidney stone.The provider made an intra-operative decision to perform SWL of the remainder of the kidney stone to complete the procedure.We were planning on submitted Current Procedural Terminology (CPT) code 52356 –59/XU, RT using ICD-10 N20.1 for the ureter stone, and then also CPT code 50590 – RT with ICD-10 code N20.0 for the kidney stone. Is this the correct way to code or is there another way?

Second scenario:The patient has a stone in the right kidney. The physician starts treating the stone with SWL. However, during the procedure, the physician notices that the stone is not breaking and makes an intraoperative decision to stop the SWL and to perform ureteroscopy with laser lithotripsy. The stone was then successfully treated and a stent was placed. Can we bill for both CPT codes 50590 and 52356, or do we need to report only what has completed the operation?

Excellent questions. For scenario 1, the provider is treating 2 separate and identifiable stones in separate anatomic locations ultimately treated with 2 different modalities (ureteroscopy with laser lithotripsy and SWL). CPT code 52356 describes “Cystourethroscopy with lithotripsy including insertion of indwelling ureter stent (eg, Gibbons or double-J type).” There is a parenthetical on this code that informs the provider to not report CPT code 52352 (cystoscopy with stent placement) or CPT code 52353 with CPT code 52356 when performed on the same side. CPT code 50590 “lithotripsy, extracorporeal shock wave” is not excluded by the parenthetical.We agree with the codes you chose.

Scenario 2 is a bit more challenging as there is just one stone. On one hand there is different work and approaches of CPT codes 50590 and 52356, so one would reasonably conclude that reporting both CPT code 50590 (appended with modifier –52 for reduced service) along with CPT code 52356 is the best and most accurate coding, which would be the best approach for non-Medicare insurers.Medicare however follows the National Correct Coding Initiative (NCCI) Edits Policy Manual which states that multiple methods of performing a procedure cannot be performed at the same patient encounter and that if an initial approach fails and is followed by an alternative approach, only the completed or last uncompleted approach may be reported.Therefore, only CPT code 52356 should be reported for Medicare beneficiaries.

For both scenarios it is important to follow the insurer guidelines for that patient. And as always, accurate documentation is important to be able to support the codes chosen.

Challenge is presented by switching from SWL to ureteroscopy intraoperatively.


Same-side shock wave lithotripsy, URS present coding questions

Although Medicare is a federal program, the 50 states, along with the District of Columbia and Puerto Rico, are divided into 12 jurisdictions. Medicare then contracts with private companies to administer the program for those jurisdictions. These private contractors are called Medicare Administrative Contractors (MAC) or Carriers. Each MAC has flexibility in policy development for payment protocols if the policies do not violate national Medicare directives. Each MAC is also charged with responsibly guarding the beneficiaries within the Medicare program. The Centers for Medicare & Medicaid Services has an interactive Medicare Jurisdiction Map noting state and MAC with contact information on the Medicare website: https://go.cms.gov/3xXOyg6.

Over the years, Medicare has encouraged the MACs to develop policies based on location with input from physicians in the state working in conjunction with state medical organizations. The system has evolved. It is our understanding that MACs are encouraged to communicate with one another to provide some consistency across jurisdictions as they develop payment policies; however, they are not required to mimic payment policies developed for other jurisdictions. Medicare requires all MACs to adhere to updated processes for developing and releasing payment policy and to participate in supporting a centralized policy location tool; Medicare centrally continues to develop national policies when deemed appropriate.

Under current Medicare protocol, carriers are allowed to develop local coverage determinations (LCDs) based on current medical practice and necessity to provide general coverage guidance for services provided to Medicare beneficiaries. Each LCD must be developed with active stakeholder input and after being issued as a proposed policy with comment period before it is finalized and adopted. The MAC is required to respond to all comments submitted during the designated review period. After consideration of the comments, the MAC can revise and publish the policy.

Coding/billing instructions associated with an LCD are communicated in local coverage articles (LCA) because the LCD is intended to outlast any possible coding changes that may occur each year. A MAC may issue an LCA without a corresponding LCD to provide coding direction for services that may not require a full LCD. LCDs and LCAs can be found on the Medicare Coverage Database and on MAC websites.

On April 17, 2022, a multijurisdictional LCD for Multiplex Nucleic Acid Amplification Test (NAAT) Panels for Infectious Disease Testing was published. This was not adopted for all jurisdictions but rather for the following MACs: Wisconsin Physician Services Insurance Corporation; CGS Administrators, LLC; Noridian Healthcare Services, LLC; and Palmetto GBA.

The LCD followed Medicare protocol, with several national meetings with participation from stakeholders in 48 states and Puerto Rico. Comments on the LCD originally released in 2021 resulted in an amended LCD based on comments from stakeholders participating in meetings and submitted separately during the designated comment period.

Each MAC has also issued an associated LCA with coding instructions and limitations on coverage. All states affected by the LCD and LCA participate in the MolDX program administered by Palmetto GBA. The LCA includes coverage and coding instructions for the use of these greater than 5 tests per specimen (often referred to as PCR testing) for urinary tract infections (UTI) and sexually transmitted infections.

In summary, each laboratory within these jurisdictions that performs NAAT panels for infectious diseases will need to apply for a Z code through the MolDX program. More specifically, each lab will need to apply for a unique Z code for each panel of tests being ordered/performed.

For example, if a urology group has 3 separate test panels for UTIs, the group will be required to obtain its own unique Z code for each test panel. For those groups using a reference lab for such panels, the lab will need to apply for a Z code and request sharing. If a group has multiple lab locations and each lab is performing the same test, only 1 application is required for the entity to which the Clinical Laboratory Improvement Amendments are assigned.

Once the application is submitted, MolDX will perform a technical assessment prior to issuing the Z code. After the technical assessment is completed and the Z code is issued, the lab will receive notification, Z code, and billing instructions. Billing for a panel test is usually cross-walked to a CPT type code and not reported with the Z code issued. The following link will provide additional information on the process: https://bit.ly/3rVAf7U.

It should be noted that within the LCAs for each of the MACs there is a reference—either in the article that became effective April 17, 2022, or in the comments in response to requests from those within the MAC—that there are no FDA-approved UTI panels. Billing for UTI NAAT (PCR) tests will not be allowed until the technical assessment is complete and the Z code is issued, nor will the system allow for retroactive billing of these tests.

The remaining MACs (First Coast Service Options, National Government Services, and Novitas Solutions) do not participate in the MolDX program and Z codes are therefore not required. However, these MACs can implement these LCDs or similar ones if they choose to pursue this in the future. Instead of Z codes for these states, panel tests will likely be reported under Proprietary Laboratory Analyses (PLA) Current Procedural Terminology (CPT) codes. PLA codes can be obtained from CPT and are alphanumeric. Obtaining a PLA code is not as time consuming as standard CPT code applications. PLA codes are issued quarterly by the American Medical Association. PLA codes were designed to allow specific lab test protocols/panels to be assigned a grouped service code for accurate reporting and adjudication. If you practice in a jurisdiction served by one of the MACs that does not participate in the MolDX program and has not issued an LCD, you will not be required to change your current billing practices.

Regardless of one’s location, the response by the MACs to this issue indicates that billing for PCR services has been noted as a potential area for abuse. We have spoken with many practices considering and/or implementing this tool for diagnosis and subsequent treatment of UTIs and other urologic problems. Most groups understand well the requirement, regardless of published billing protocols, that all claims submitted for payment must be medically reasonable and necessary. Number of tests ordered/performed and presenting complaint/condition of the patient must be accurately noted in the medical record. Many practices have also developed clinical guidelines for the appropriate use of PCR testing. As more published peer-reviewed articles address these tests, we would expect Medicare and other payers to adapt payment policy and coding guidance to any new clinical findings.

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

Labs will need to apply for unique Z code for each panel of tests ordered.

Mark Painter

Articles

How do you bill for a 75-minute audio-only E/M visit?

What is the best way to report an encounter when both the kidney and bladder are imaged?

Same-side shock wave lithotripsy, URS present coding questions

LCD addresses NAAT panels for infectious disease testing