OK to bill orchiopexy with hernia repair, CPT says

October 1, 2004

Q A pediatric urologist I code for is concerned that we cannot bill/code for both orchiopexy and a hernia repair done during the same operating room session. Do you have any documentation on this matter? When you look up 54640 in CPT 2004, it references, "For inguinal hernia repair performed in conjunction with inguinal orchiopexy, see 49495-49525." In the Medicare Correct Coding Guidelines, I do not see any edits stating not to bill both procedures together.

A This issue is definitely confusing. I can understand the frustration you were feeling when you wrote the question. In fact, I'm not sure you could exceed the level of ambiguity achieved with the terminology and billing suggestions for 54640 in CPT-by definition, "Orchiopexy, inguinal approach, with or without hernia repair." Yet, in parentheses, it states, "For inguinal hernia repair performed in conjunction with inguinal orchiopexy, see 49495-49525."

Fortunately, the publication "CPT Changes 2001: An Insider's View," clarifies the issue (see pages 98-99). It says, "When an inguinal hernia repair is performed in addition to an orchiopexy, both code 54640 and the appropriate inguinal hernia repair code 49495-49525 should be reported." When CPT defines a code or interprets that definition, we should follow those recommendations, unless Medicare trumps it with a rule of its own.

Q My urologist began doing a new lab procedure using the patient's urine on a test strip to check bladder tumor urine. I was told to use CPT 86294, but after reading the coder's reference guide, I thought the test was done with blood, not urine. Can you verify if CPT 86294 is still the correct code I need to use?

A Code 86294 (immunoassay for tumor antigen, qualitative or semi-qualitative [eg, bladder tumor antigen]) does not specify the source that is used for the test. Therefore, it can be used for any specimen-including blood or urine-if the test meets the description for the code.

One would have to be sure that the test is a quantitative (or semi-quantitative) immunoassay to detect tumor antigen. If it meets the definition, then 86294 is the correct code. Remember, Medicare can change the rules. Check to see if a local carrier decision (LCD) is in place for this test, specifically.

Q Increasingly, payers are not reimbursing for first-time patient consultations that precede a surgical procedure. It seems reasonable to expect reimbursement when the service is a preoperative consult. Any recommendations? What about using a diagnostic code such as "hematuria" or "abdominal pain" for the consultation, then identifying the procedure by a different diagnosis, eg, "renal stone?"

A The initial evaluation of the patient should always be paid, even if a surgical procedure is performed. Medicare will always pay if you actually take a history, perform a physical, and provide medical decision-making services-if you code correctly and use the appropriate modifier. With very few exceptions, this describes all initial encounters. All private payers should pay unless you have contractually agreed to perform the service without payment.

Be sure that you are coding correctly. For Medicare, the -25 modifier should be attached to the E&M code if you are performing a 0- or 10-day global procedure on the day of the evaluation. If the procedure is a 90-day global procedure, then the -57 modifier must be attached to the E&M service performed, on the day before or the day of the procedure in which the decision to perform the procedure was made. A different diagnosis is not required. A private payer may follow Medicare rules, or may pay only if the -57 modifier is used.

Always appeal if you're not paid correctly. Also, add to your contract that the private payer will pay for the consult the next time you renew your contract.

Disclaimer: 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.