How to bill for hospital consults without physical exam

November 14, 2018
Ray Painter, MD , Mark Painter
Volume 46, Issue 11

Charging by time is permissible with appropriate documentation, according to Ray Painter, MD, and Mark Painter.

Ray Painter, MD

Mark Painter

What is the best way to charge for a consult at the hospital that does not require a significant physical exam? For example, I was asked to see an old Medicare patient of mine who was in urinary retention following a major surgery. My billing department told me that I could not charge without documenting a physical exam.

You have asked a very important question for urologists. First and foremost, your billing department is correct. A Level 1 initial hospital care code requires a detailed physical exam (at least four exam points for the affected organ system, in this case the genitourinary system, and at least four exam points in other organ systems).

Without the required history and physical exam, we recommend using the subsequent hospital care code that is satisfied by your documentation for the visit. Some medical directors have recommended using an unlisted evaluation/management code; however, this method of reporting is much more problematic and should be pursued only if required by the payer.

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For future consults that do not require a significant amount of physical exam, we recommend considering charging by time, if over 50% of the time has been spent in counseling the patient and coordinating care. Charging by time in the hospital includes the total time spent on the floor, talking to the nurse, reviewing the chart, discussing the issue with the patient, taking a history, performing the medically necessary physical exam documenting the encounter, etc. Three things should be recorded in the chart:

  • specific total time indicating the time spent with the patient, and the floor time as indicated above
  • time spent in counseling the patient or include the statement that “over 50% of the time was spent in counseling and coordinating care”
  • issues/data discussed with the patient.

The average time to accomplish a Level 1 recorded in the CPT book is 30 minutes. This is considered an average time and not a “threshold” time. If you spend less than 30 minutes, you can still charge this code (99221).

Next:Is −25 modifier needed for E/M service when charging in conjunction with 5XXXX code?My biller said she heard at one of your seminars that we did not need to append a −25 modifier to an E/M charge in conjunction with 51798. This does not seem to be correct. I specifically remember being told many years ago that we had to attach a −25 modifier to any E/M service when charging in conjunction with any 50000 code.

We’re glad you asked that question. We can see that there is still lot confusion on this issue, as we audit hundreds of urology charts each year.

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Many years ago, what you were told was correct. All of the 5XXXX codes were either 0-, 10-, or 90-day globals. Charging an E/M service with any CPT code from the Surgery section would require the appropriate modifier, and –25 is the most appropriate in the majority of cases.

However, as time changes, so do Medicare rules. Your biller is correct at this time. When billing Medicare, you do not need a –25 modifier attached to the E/M when billing with 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging).

51798 is listed as “Global:XXX” and by definition, the global concept does not apply to the code. Uroflow (51736 and 51741) and electromyography (51784 and 51785) are also classified as XXX procedures. For Medicare patients, do not add the −25 modifier to an E/M code when billing in conjunction with an XXX global procedure. In addition to the above, 51741, all laboratory services (including urinalyses), and imaging procedures are listed as XXX global services.

The exception to that rule are the few XXX procedures/services that include E/M services in the bundled service list under the NCCI edits.

An example of an XXX global procedure that requires a modifier for an E/M code reported on the same date is 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic).

Also see -NP, PA incident-to billing: What is (and isn’t) allowed

If you check the bundling matrix in, you will be able to see if a modifier is required for E/M code by entering all codes to be charged that date and clicking “analyze codes.” The bundling matrix will indicate whether an E/M code needs a modifier for either an NCCI bundle or a global period bundle.

Next:Question regarding laparoscopic pyeloplasty and stent placement through ureterotomyI have a two-part question for you. First, if you perform a laparoscopic pyeloplasty, can you bill 50605 as well as for stent placement through a ureterotomy? My hospital system is saying they are bundled, but I don’t think they are. Second, when I do a ureteroureterostomy, I feel code 50605 should be allowed, but they keep denying my coding. Can you help me to set the record straight?

Regarding your first question, the description of 50544-Laparoscopy, surgical; pyeloplasty-does not include insertion of a stent in the description. Nor is there a different code that would include both the stent insertion and pyeloplasty. Therefore, from a CPT coding perspective, it is appropriate to look for a code that would describe the insertion of a stent to report in addition to the laparoscopic pyeloplasty.

Unfortunately, CPT does not include a code for laparoscopic insertion of stent. Expanding the search, we find two potential codes that could be considered: 50605 (Ureterotomy for insertion of indwelling stent, all types) and 50949 (Unlisted laparoscopy procedure, ureter). Choosing which code to use is a bit of debate. Code 50605 does not specify approach in the description. The AUA has recommended in other cases for circumstances in which there is no existing laparoscopic code for the procedure performed, with payer notification, a code considered to be traditionally provided with open approach but without a specified approach in the descriptor can be reported for the service. Note that payer notification is recommended prior to reporting the service. Many groups are successfully reporting in this manner.

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However, for those instances where the payer prefers the use of the unlisted code or in circumstances in which the compliance program for the billing entity requires reporting of the unlisted code specifying approach, the unlisted code with reference to the compatible open code should be reported.

Neither of the codes are considered bundled with the pyeloplasty code in the National Correct Coding Initiative (NCCI) bundling edits. Therefore, you should charge separately for the insertion of the stent when medically necessary. It should be noted that not all payers conform to NCCI bundling edits; as such, you may encounter some payers that will not allow separate payment for the stent insertion.

Finally, NCCI edits change quarterly. This answer was correct at the time of publication, but you will need to make sure that edits do not change for future billings. Note: As we have stated many times before, documentation for all procedures should support the medical necessity for performing that procedure at that encounter. If medical necessity cannot be supported, the procedure should not be charged.


Addressing your second question, the description of 50760 (Ureteroureterostomy) does not include insertion of the stent. The two codes are bundled in the NCCI, but could be unbundled with the modifier. However, since the stent is being inserted because of the procedure and is related to the procedure, there is not a good modifier that will pull you out of the bundle. We would recommend that you not bill for the insertion of the stent separately.

Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at 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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