Is billing for stone prevention counseling possible?

I have a patient that had an extracorporeal shock wave lithotripsy (90-day global), and the physician saw the patient within the 90 days to counsel the patient on how to prevent future stones. The physician wants to bill an evaluation and management. Can this be done?

This is a great question and one we have discussed frequently over the years. The answer is maybe.

READ: Modifiers for multiple stones raise questions

As we have discussed the issue among ourselves and with others, we have been forced to conclude at this point that you should not charge for stone prevention during the global period of a service provided to treat stones for the routine patient. However, for those patients who truly have an underlying condition diagnosed by the physician that will more than likely cause additional stones and will require more medical management and provider effort than the average stone patient, you should consider reporting the visit.

To arrive at a more detailed and targeted answer, you have to ask yourself several questions. Was the discussion of a routine nature that is needed with most stone patients? What was the medical necessity for having that discussion with this patient? Was the discussion related to stone prevention, or was it for the treatment of a disease process? Was there significant, extra work performed over and above the routine follow-up for the surgery?

NEXT: Looking at the definition of modifier –24

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First, we looked at the definition of the only modifier that will allow billing for E&M services during a global period, modifier –24: “Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.”

The argument that the prevention of stones is unrelated to the reason for the procedure is one that we have formulated and discussed several times. The argument goes something like this: “Clearly, the stone burden removal with ESWL is directed at existing stones, which are considered to be treated during the procedure, and the related care will include monitoring the success of the procedure as well as treatment for recovery. As the counseling for a patient is intended to ‘treat’ future stones through prevention, it appears the definition of modifier –24 would allow for reporting the E&M service provided.”

One of the problems in the end is the potential for nonpayment by a payer. If a payer considers the overall treatment of the stones as the   problem for which the ESWL was provided, then the discussion of prevention could be considered a part of the global care of the patient. Is it common procedure for a physician to discuss prevention of a problem as a routine in the care of a patient? Is it good medicine to simply treat the stone burden and not advise the patient of ways to prevent this problem in the future? It is hard to argue that good patient care would not include this discussion. Many payers have latched on to this, and therefore consider care that is provided to a patient relating to stones as not unrelated and therefore should be included in the global.

NEXT: Definition of the global period

The other definition we have considered is the Medicare definition of global period and, specifically, what is not included in the surgical package. According to the Medicare Claims Processing Manual (Chapter 12-Physicians/Nonphysician Practitioners Section 40.1.B Services Not Included in the Global Surgical Package), the following visits are considered payable within a global period:

• visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery

• treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery.

There are other items in the list, but these are the most relevant to this discussion. The first point, indicating visits that are unrelated to diagnosis for which the surgical procedure is performed, is hard to get around. It is hard to declare that the treatment is for a condition unrelated to the reason for the surgery. The stone likely was present due to the patient’s metabolism and underlying condition.

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Regarding the second point, it would appear that the visit would be allowed for those cases that go above and beyond the normal care provided to the majority of patients in the recovery period.

From a processing standpoint, if the diagnoses are the same or considered to be related within Medicare’s database, the claim will be denied and an appeal will be required. Based on the list of services not included in the Medicare-defined global, it would appear that one would need to satisfy only one of the bullet points listed. Therefore, documentation must support that the condition is underlying and indeed an added course of treatment that is clearly not a part of the normal recovery from surgery is necessary. Even with these arguments met, the fact that the visit is related to the reason for the surgery may result in a second denial of the service.

NEXT: Treatment vs. prevention

The final issue we have considered is a discussion regarding treatment versus prevention. Medically necessary and reasonable treatment is covered by Medicare if other rules are considered. Prevention, on the other hand, is only covered under specific circumstances. This fact may also prevent coverage, as payers may not consider the fact that you are treating the underlying diagnosis and consider any lifestyle changes recommended as preventive services and therefore not covered, even in a situation where the patient is outside the global.

In summary, if this is a routine discussion following a stone removal in which you are recommending increased fluid intake, some dietary changes, etc., then perhaps, for reasons stated above, such as minimal extra work, routine good patient care etc., there should not be an additional charge for this type of service provided in the global regardless of payer.

However, if this patient has a problem such as abnormal lab work, the diagnosis of underlying causes for recurrent stones, etc., requiring significant, medically necessary additional work, then this service could be legitimately charged. Documentation should clearly identify the reason for the visit and the treatments prescribed and, for Medicare at least, you must be prepared for an appeal and perhaps an uphill battle for final payment.

The bottom line, for the submitted question, is that we would need to see the documentation for that visit before we would say “yes” or “no” as to our recommendations in charging for this service, as the circumstances will dictate the answer.

NEXT: OK to bill two instillation codes for one appointment?

We would like to know if it is OK to bill two instillation codes (51700) for one appointment. The scenario is that medications are being placed within the urethra to treat conditions of the urethra, and subsequent to that, medications via catheter are being placed within the bladder to treat a condition within the bladder. I have asked a couple of sources to weigh in on this. One brought up that the urethral treatment might be considered anesthesia prior to the bladder treatment, in which case it would be included. Another source said, “I would bill the 51700 only once as this CPT code has a medically unlikely edit (MUE) of 1, indicating this code can only be billed once per encounter. The clinical scenario does not indicate that modifier –59, one of the new X modifiers, or other modifier would be correct in obtaining payment for a second 51700.”

Could you please provide us with your opinion? I have included a sample chart note of this procedure:

“Heparin Instillation: Patient was prepped using DMSO, sodium bicarbonate, and lidocaine gel at the urethral meatus and suprapubic heat prior to the procedure. Betadine prep was performed followed by insertion of an 8F pediatric catheter without incident. The following medications were mixed and instilled: heparin 40,000 unit injection solution; bupivacaine (PF) 0.5% (5 mg/mL) injection solution; lidocaine (PF) 20 mg/mL (2%) intravenous solution; sodium bicarbonate 1 mEq/mL (8.4%) intravenous solution. The catheter was then removed.”

Continue to the next page for the answer.

Based on the information you have provided in the note above, we would recommend charging 51700 only once. Our reasoning is as follows:

• It appears from the note that the solution for the urethra is in fact used as a preparation for the procedure. “Patient was prepped using DMSO, sodium bicarbonate, and lidocaine gel at the urethral meatus and suprapubic heat prior to the procedure” (emphasis added). This would indicate that the treatment is provided to prepare the patient for treatment. Based on the medications used and the lack of any clear diagnosis or reason for treatment of the urethra other than to prepare for the insertion of the heparin, the service appears to be that of a local anesthetic. As local anesthesia is included per CPT global guidelines, the service is included in the instillation of the heparin and should not be reported, regardless of payer.

• The definition of code 51700 in CPT is “Bladder irrigation, simple, lavage and/or instillation.” The code by definition does not include a mention of urethral instillation; reporting this code for the urethral portion of service described is not appropriate. Unfortunately, the urethral instillation does not have a code in CPT at this time. Based on this, we would not recommend reporting 51700 to any payer for the urethral portion of the service.

• The MUE for code 51700 is in fact 1. This edit is specific to Medicare and those payers that have adopted this rule for payment. While this issue is clearly payer specific, it is also fairly commonly used with larger payers. MUEs are problematic to work around without a clear medically necessary reason and manual review. The note you have included as mentioned above does not support exceeding the MUE for this code.

Your further comments with regard to the –X [E, S, P, U] and –59 modifiers are correct based on the definition of global listed in the first bulleted item in relation to the documentation that you have provided.

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.

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