BPH counseling: Can you charge a level III visit?

A patient was seen in the office with a urinary tract infection, problems with urination, and a history of gross hematuria. The patient was treated with an antibiotic, a computed tomography scan was ordered, and a cystoscopy was scheduled. On the return visit, the patient was told that the urine culture was negative and the CT scan was normal. A cystoscopy was performed and the patient was found to have BPH with significant obstruction. The problem of BPH and the potential treatment were discussed, including the urologist’s recommendation for a laser prostatectomy. A total of 25 minutes was spent in counseling the patient.

The doctor wants to charge a level III established patient visit. I’ve tried to tell her that the E&M is included in cysto, but she won’t believe me because she’s heard you say she could charge. Please help.

Your doctor is correct. Since the discussion was on the “treatment” of the disease process and not merely a discussion of the findings of the cystoscopy, that service would be considered “separately identifiable.” The time spent was well documented and certainly should be considered “significant.” Therefore, the encounter meets the definition of the –25 modifier: “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service,” and should be charged separately.   

Related - ICD-10: Different codes but identical guidelines

The time spent was 25 minutes, which is closer to a level IV (30 minutes) than a level III (15 minutes), and since the times are average times and not threshold times, the appropriate charge would be:

• 52000

• 99214–25.

NEXT: Procedure code for bladder hydrodistention under moderate sedation?

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What is the procedure code for bladder hydrodistention under moderate sedation?

There is no specific code for bladder hydrodistention under moderate (conscious) sedation. However, there are codes for the dilation of the bladder for interstitial cystitis under general or spinal anesthesia: 52260-Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia. There’s also a code for the same procedure under local anesthesia: 52265-Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia.

Read: How to code for prostate needle biopsy

If the hydrodilation was performed because the patient has interstitial cystitis, under moderate (conscious) sedation we would recommend reporting code 52265. If the procedure was performed in a hospital or ambulatory surgical center and the sedation was given by an anesthesiologist, the work would more closely mimic 52260. However, since it specifically states “general or conduction (spinal) anesthesia,” a –52 modifier would be required and processing of the claim would result in lower payment, thus our recommendation for 52260. (We are assuming the local anesthesia is used in addition to the sedation.) If the service was provided for another disease, we would recommend 51700-Bladder irrigation, simple, lavage and/or instillation or 53899-Unlisted Procedure. None of the codes listed include moderate (conscious) sedation according to CPT guidelines. Therefore, depending upon payer rules, you may report codes 99143-99149 depending on who provided the sedation monitoring and the amount of time spent.

NEXT: Advice on CPT codes for re-positioning of ureteral stent by radiologist

Please provide advice on the CPT codes used for the re-positioning of a ureteral stent by a radiologist.

We would need to know the details of the procedure in order to specifically answer your question. What portal of entry did the radiologist use? Was the stent removed and reinserted? Was the catheter manipulated from the bladder or from the kidney? Providing us with the operative report would be most beneficial.

There is no specific CPT code for repositioning of a ureteral catheter by a radiologist. However, there are several CPT codes to be used by radiologists for inserting and/or removing ureteral catheters, depending on the specific work performed.

Examples:

• 50386: Removal (via snare/capture) of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation

• 74480: Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation.

You ask specifically for CPT codes; therefore, we assume that you were not asking for billing advice. If that assumption is wrong and you are requesting recommendations for appropriate billing, we would not be able to give that advice without knowing your specific payer billing rules and the documentation developed to support the service rendered.

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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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