Separate supporting documentation for each service provided is recommended
Q Urodynamics continues to be a tremendous challenge for our coders. Can you provide information on what is expected in terms of documentation to identify the actual study components performed? What would an auditor be looking for (graphs and summary report, interpretation, procedure write-up by the tech)? Common practice for our group is to have the studies performed on a separate date by a tech, with a future reading/interpretation by the physician. Is correct practice to split these services in this case? Should there also be a brief procedure description by the tech when the studies are performed?
A You are not alone in your difficulties. We recently participated in an audit of urodynamics charges in which Medicare recognized some codes but not others, and the documentation for all services that were reviewed only included the report from the urodynamics machine.
This review pointed out the lack of understanding of these codes by the payers and physicians. As these codes contain both a professional and a technical component, we look for guidance on documentation from the radiology codes. The primary statement that provides guidance for documentation is a directive that Medicare should pay for a professional component only if there is a written report.
Therefore, we recommend that each service that you bill for includes some separate documentation with the information generated during performance of the test to document the technical component (TC). Use a simple template for the professional component (PC), with at least one statement on test performed, cystometrogram (CMG), bladder pressure, urethral pressure profile (leak point or UPP), abdominal pressure, and electromyogram (EMG). However, as an auditor, we would not down-code the services if there is documentation supporting that the information was reviewed and a diagnosis or opinion on the condition has been formulated.
As far as split billing, it is accurate to report the services provided on the date the service was actually provided. Therefore, your circumstance where the technical component is provided on a different day than the procedural component should be billed as technical component on the day performed (code with modifier –TC) and professional component on the day read (code with modifier –26) on a different day. If the payer requires global billing (billing of the codes with no modifier), we recommend you obtain that directive from the payer in writing.
