Modifier not required to report CPT code 51702; correct place of service is all that’s needed

Our doctor is called to consult on a patient in urinary retention. The hospital nursing staff is unable to pass the Foley catheter. During the consult, the doctor places the Foley catheter. The physician bills for the hospital-visit evaluation and management and CPT 51702, but I think I’m thinking too much because the lay terms of 51702 state the physician supplies the Foley… so it’s still OK for my provider to report the E/M and 51702, and the hospital will bill for the supplies only. Is this correct? Or is there a modifier that can be added to the 51702 in order for the doctor to bill for the placement? 

With our complicated billing system, it is easy to “think too much.” Before we get to the meat of your question, we should issue a warning: Don’t let the “lay terms” sidetrack your thinking. “Lay” descriptions are helpful to many in understanding what a service or procedure may entail, but these descriptions are not a part of CPT or any other official rule set. In short, consider them as additional information, but do not use this information to guide or change your coding.

For your questions, we “think” it would help to reword your question and then answer with more than a simple yes or no.

First, is it OK to bill for 51702 in the hospital setting?

When you’re paid for the procedure in the office, you are paid a higher fee than when you perform the same procedure at the hospital. Look up 51702 in AUACodingToday, scroll down to “fee schedule,” and look at “facility fee.” The national payment is $27. The non-facility fee, or office fee, is $65.88. This additional payment is for the catheter and the office expenses. In short, it is not only OK to report 51702 in the hospital, it is in fact the correct way to report the simple insertion of a Foley catheter in the hospital.

Also by the Painters: It’s time to declare war on costly billing mistakes

Second, do you need a modifier to report 51702 in the hospital?

No, the correct place of service is all you need to communicate to the payer that the hospital is charging a “facility fee” in addition to your charge for the procedure.

We assume that you do know you will need a modifier –25 attached to the E/M code to report the consultation (E/M code) on the same date as the catheter insertion.

A press release from Imprimis Pharmaceuticals, Inc. includes the following: “According to the [AUA], bladder instillations are considered a second line treatment option when self-management treatments do not provide symptoms relief. Hep-Lido-A’s new user-friendly kit includes a hydrophilic catheter, and ready to use sterile pre-filled syringes, providing added convenience for in-office instillation as well as for patients who perform at-home instillations.” I have two questions about this. First: Are there different coding requirements for in-office procedure versus home? Second: Can you bill separately for the kits? If you can, what codes do you bill?

Code 51700 (Bladder irrigation, simple, lavage and/or instillation) is the correct code to use when a physician or employee of the physician instills a drug like Hep-Lido-A in the office setting. Payment for services in the office include typical supplies like gloves, exam table paper, local anesthesia if used, syringes, catheters, etc. Drugs (other than drugs used for local anesthesia) are typically allowed as a separate charge, unless they are considered to be self-administered drugs (SADs). SADs are defined typically as drugs administered by the patient over 50% of the time.

Unfortunately, the administration of Hep-Lido-A for interstitial cystitis does not match typical administration for heparin sodium or lidocaine HCL assigned to the J codes for these drugs. Therefore, reporting of Hep-Lido-A will require J3490 (Unclassified drugs) with a description of the drug in box 19 and most likely an invoice proving that you paid for the drugs as well as the amount. Payment for the drug “kit” under J3490 should be checked with the payer prior to administration.

SADs are not covered under Medicare Part B. Therefore, you cannot bill for kits provided to the patient for self-administration using CPT codes to your Medicare carrier.

Even though SADs are not covered by Medicare Part B, the kits may be eligible for coverage under Part D Medicare. If you are considering dispensing kits for home use, you will need to look into obtaining a pharmacy license. Requirements for these licenses vary by state and payment for SADs will vary by payer. Many offices have obtained the correct licensing to dispense SADs to patients.

Exploring in-office pharmacy and the benefits to the practice and your patients will require a careful study of your facility, your demographics, and your staff. We recommend development of a full business plan prior to executing the work required for licensing.

Is it true that penile modeling during inflatable penile prosthesis placement for penile curvature is included in the prosthesis insertion bundle (CPT 54405), or can it be billed separately with CPT 54360?

The description for code 54405 (Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir) is straightforward for the insertion of the IPP, with no mention of modeling or angulation correction.

According to the National Comprehensive Coding Initiative edits (as checked on AUACodingToday), 54360 (Plastic operation on penis to correct angulation) is not considered to be bundled with code 54405. These services would suggest that both codes may be reported to Medicare and private payers.

However, the global definition of a procedure in CPT and in payment protocols for Medicare and most private payers dictates that services commonly required to complete a procedure should not be reported separately. Therefore, you should consider the efforts required on each patient in whom you implant an IPP. If the services provided are atypical due to clinical presentation and require significant extra effort to correct the angulation above and beyond the standard IPP insertion, reporting of both services should be allowed.