I was performing avasectomy in the office but had to discontinue the procedure because the patient could not tolerate it. The incision had been made. Should I bill this with the –53 modifier or should I bill an E&M service? The procedure was performed 2 days later in the outpatient surgery center under sedation.
The first procedure should actually be billed with the –52 modifier (Reduced Services), not the –53 (Discontinued Procedure). The –53 modifier should be used if the procedure was discontinued due to extenuating circumstances that threaten the patient’s well-being.
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In addition, be sure the operative note documented that the procedure would be performed at a later date. The second procedure should be billed with the –58 modifier (Staged or Related Procedure or Service by the Same Physician During the Postoperative Period), since it was performed in the global of the first procedure, was planned, and was not a complication. The –76 modifier (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional) would be appended since this is a repeat procedure code. Modifier –76 is informational only but would send a message that this is not a duplicate charge.
The doctor I work for saw 38 patients during about 7½ hours of actual patient care time. About half were level IV, some were level III, and a few were level V. There were several new patients but most were established. I added the times for each of the codes as listed on the E&M pocket card. He billed for over 13 hours of work. How can I convince him that he’s going to get into trouble if he continues? I read about a psychiatrist who went to jail for overcharging his time.
Excellent question and a very timely, important topic. If all the visits were charged based on time, you are correct that this is a big problem. However, if you're charging based on components, which most urology visits are, then time is not a consideration. In fact, if you're charging based on the components, do not document the time spent or in and out time. If the physician is providing medically necessary services, documenting the services provided and the reason for providing those services, and the codes accurately reflect the documented services, there should be no problems even if audited. Again, if charging by components, time is not a consideration.
We think the psychiatrist you referred to had charged all of his visits by time and the time added up to more than the office day (9 a.m. to 6 p.m.).
I have been billing for an E&M code on the same day as a uroflow, using a –25 modifier. One of my colleagues said that she heard in one of your seminars that you didn’t need a modifier. Is that correct?
Yes, that is correct. If you’re billing Medicare or anyone that follows Medicare rules for an E&M service on the same day as a uroflow, a modifier is not needed. Several years ago, Medicare changed the global designation of uroflowmetry procedures to “XXX” and drastically lowered the payment for the procedures. “XXX” means that global rules do not apply.
Therefore, a 51741 (complex uroflowmetry) can be performed on the same day as an E&M service or in the global period of another procedure without the need for a modifier. Those are the rules; however, some private payers may not use the global designation of Medicare. In that case, you may need to use a modifier just as you would with any other procedure.
51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) is another “XXX” procedure. The same rules would apply.
Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at UT@advanstar.com. 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.