How to charge for E&M services, procedure on same date

Our office has adopted a policy that does not allow coding for an evaluation/management visit on the same date as a previously scheduled cystoscopy. At your course, you said that if an E&M service is separate and identifiable, you can charge for the E&M with modifier –25. If I talk to a patient and/or treat BPH and ED on the same date as a scheduled surveillance cystoscopy, can I charge an E&M with a modifier –25?

E&M services reported on the same date as a procedure with a global require that the E&M service is separate, significant, and identifiable. There is nothing in the requirement for there to be a new problem, nor is there a rule that states you cannot charge an E&M code on the same date as a previously scheduled service. A cystoscopy has a 0 day global, which includes the related preoperative care, the procedure itself, and the postoperative care, including telling the patient the findings of the services. The postoperative care does not include discussing or treating the disease process related to the procedure or any other disease process. All services regardless of whether they are new or established that are addressed on the same date can be charged if the E&M service is not a part of the procedure(s) provided and it is documented appropriately and accompanied by the –25 modifier.

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BPH and ED are not related to bladder cancer in your example above. If your E&M note demonstrates the service provided was significant and is identified by appropriate documentation, you are clearly justified in using the modifier –25 on the E&M service and charging both the cystoscopy and E&M.

Remember that you are not required to have a separate diagnosis for the modifier –25 as long as you meet the definition. For this, consider the patient that is in for a surveillance cystoscopy during which you discover a new growth. The appropriate diagnosis for the cystoscopy is now either “Cancer of the Bladder” or “Unspecified Neoplasm of the Bladder” because that is what you know at the end of the encounter. If you then sit down and talk to the patient about the next steps in treatment of the new growth, the time spent in that discussion is also billable under modifier –25, as the E&M service is separate, significant, and identifiable. That diagnosis would be the same for both.

Next: Coding for sling and cystocele repair with mesh repair

We recently tried to submit a claim for sling and cystocele repair with mesh repair, but our edit tool blocked the 57267. We used codes 57288 (Sling operation for stress incontinence [eg, fascia or synthetic]), 57267 (Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach [List separately in addition to code for primary procedure]), and 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele). We checked CPT and 57240 is a parent of the add-on code 57267. Can we bill this code?

The reason your editing tool blocked 57267 is that the Correct Coding Initiative included a new edit in the third quarter that became effective Jan. 1, 2017 that now has 57267 included in 57288. This edit is another example of how little the folks at CCI respect or understand CPT coding. 57267 is an add-on code that has a list of required parent codes (45560, 57240-57265, and 57285) included in the parenthetical. As a refresher, a parent code is a code that is required to be reported at the same time as a designated add-on code. Add-on codes in general should not require a modifier and should not be reduced under multiple procedure reductions.

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We can only guess that the CCI folks saw a number of claims in which codes 57288 and 57267 were reported on the same claim. Medicare has a set of edits for add-on codes that would deny a 57267 if the claim did not include a parent code from the list above. Therefore, we must also assume that at least one of the parent codes was included on the claims with 57288 and 57267, allowing the codes to process. It is unclear why CCI thinks that someone coding a sling, cystocele, and mesh repair would not be using a separate mesh material to repair the cystocele in every case.

Regardless of why this decision was made, for now you will need to add a –59 or –XS to code 57267 in order to report the use of mesh for the separate repair of a cystocele when reporting a sling for the same date.

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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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