As most urologists have already heard, there are some significant changes to the coding and reimbursements for Urodynamic evaluations beginning 2010. Before I begin to explain these changes, I would emphasize that good urodynamic evaluations are still a very valuable diagnostic tool and remain an excellent profit center, despite the decline in “margins” compared to recent years.
There are several new urodynamic CPT codes in 2010 which combine two or more codes that were most often billed together in previous years. The decrease in reimbursement has come about mainly as a result in CPT changing and combining several codes and decreasing the practice expense Relative Value Units “RVU”s associated with them. Apparently, the limited survey data returned by sampled urologists supported this RVU reduction. This is a wakeup call for all urology practices to pay close attention and complete surveys when requested. I must also note that at present, the Medicare RVU conversion factor remains the same from 2009, but soon could be adversely affected by the Sustainable Growth Rate “SGR” mandate and healthcare reform. We presently have a two month reprieve from a major hit on the 2010 SGR conversion factor. This hit would be across the board on all physician services tied to RVUs (not just urodynamics).
Back to Urodynamics….I will review and further clarify the new and most commonly performed urodynamic CPT codes. When discussing actual reimbursement, I will use the national average Medicare allowables, as they are in early 2010, as my benchmark (auacodingtoday.com).
2010 common Urodynamic CPT codes:
51726 is the historical CPT code used for the Cystometrogram (CMG), which is the filling phase part of the urodynamic evaluation (without UPP/VLPP or Voiding Pressures). CMGs are used to determine bladder sensitivity, capacity, compliance, and detrusor stability. Do not use this code if you do a CMG with UPP and/or a CMG with Voiding Pressure(s). You should use the appropriate new 2010 codes that include CMG and follow here. The Medicare allowable for 51726 will be transitioned down over next 3 years.
51727 is a new CPT code that is used when the procedure includes both a CMG and Urethral Pressure Profile “UPP” or abdominal Valsalva Leak Point Pressure “VLPP” without Voiding Pressures. A VLPP is described by the AUA and other scientists, as an evaluation of urethral pressure competency and thus billed as a UPP any technique. (http://www.auanet.org/) . Do not confuse VLPP’s with detrusor leak pressures.
51728 is a new CPT code that is used when the procedure includes both a CMG and Bladder Voiding Pressure, but not UPP/VLPP.
51729 is a new CPT code that is used when the procedure includes a CMG, a UPP/VLPP and Bladder Voiding Pressure.
51797 is the “Add On Code” that would be used to add on to the 51728 or 51729 base code to describe that Abdominal Voiding pressure was done during the bladder voiding pressure phase. This is commonly measured through a balloon in the rectum or vagina.
51741 is the Uroflowmetry (flow rate) portion study of the UDS study either performed independently or during the Voiding Pressure study.
<51784 is sphincter EMG by other than needle (i.e., surface anal sphincter electrodes)
51785 is Needle sphincter EMG (Note: this code requires a higher level of physician supervision)
Please Note: CPT 51772 and 51795 have been deleted and are no longer valid for 2010 dates of service. At this time there is no specific code to bill separate voiding pressures without CMGs (i.e., penile cuff VP technique).
You may notice that 51726 will actually allow slightly higher reimbursement, as regulation requires a historical code to transition down in coming years, at which time it will be below the new inclusive CPT code amounts. As a warning, you must always use the code that best describes the actual procedure(s) performed. Do not use 51726 if you are actually performing 51727 or 51728, or 51729 just to get a little more reimbursement. This could be considered fraudulent coding.
There are other CPT codes that can be associated with Urodynamic evaluations including: 51798 (PVR), 8100x (UA), 51702 (insert temp foley catheter) and Video-Fluoroscopic codes of 51600 (instill dye) and 74455 (VCUG) as well as an E&M visit if -25 modifier qualified. All are billable if the service is performed, documented, and properly coded.
How a urodynamic encounter appears on a claim form would depend specifically on the actual procedures performed on a specific patient during the evaluation. It would also vary depending on the site of service where the procedures were done and who is interpreting them.
For a common urinary incontinent patient UDS, the usual urodynamic and related CPT codes reported for an encounter in an office setting, (Technical + Professional Interpretation on the same DOS by the same provider, assume a level 3 office visit and UA non-automated with Micro) might include:
51729 </b>(CMG and VLPP/UPP, Bladder Voiding Prs) this is the base code.
51797 </b>(add on Abd Voiding pressure)
51784-51 </b>(Sphincter EMG)
51741-51 </b>(Uroflow Rate)
51798 (bladder volume by ultrasound)
81000 (urinalysis w micro)
99213-25 (provider level three visit if -25 modifier qualified)
The 2010 National Medicare Average for all the studies above, in an office setting by one provider would be $682.92. (base allowables from: http://www.auacodingtoday.com/ and subject to change March 1, 2010 depending on reform )
For a patient presenting in common urinary retention, codes would again specifically depend on the actual procedures performed on an individual patient during the evaluation. Codes would also vary depending on the site of service and who is interpreting the procedures. An encounter in an office global setting, (Technical + Professional Interpretation on the same DOS by the same provider) might include:
51728 </b>(CMG and Bladder Voiding Prs) is the base code. (notice no UPP/VLPP was done)
51797 </b>(add on Abd Voiding pressure)
51784-51 </b>(Sphincter EMG)
51741-51 </b>(Uroflow Rate)
51798 (bladder volume by ultrasound)
51702-59 (simple insertion of temp foley, separate procedure)
81000 (urinalysis w micro)
99213-25 (provider level three visit if -25 modifier qualified)
The National Medicare Average for all the studies above, in an office setting by one provider would be$698.98. (base allowables from: http://www.auacodingtoday.com and subject to change March 1, 2010 depending on reform)
Split Billing: As many urodynamic labs are now correctly discovering, if one Provider (with NPI) is responsible for the Technical Component of the urodynamic evaluation and another Provider (with NPI) is performing the Professional Interpretation, two claims should be filed. When this is done, the Technical Components of the Urodynamic codes require a –TC modifier on one claim. The Professional Interpretation component of the Urodynamic codes would require a -26 modifier on another claim. When billing this way, the urodynamic -TC codes are not multi-procedure priced. This means that the sum of the allowables for these two claims (-TC services plus -26 services) are more. This separate encounter billing can be a bit complicated, so if you have two providers (or two dates of services), pay careful attention to your documentation and the actual way the technical versus professional services are performed (ie., separate documentation, with separate provider signatures or DOS, etc.). In the top example above this would increase the net Medicare allowable by $73.07, again, only if the services were actually performed in this two encounter fashion.
Because proper urodynamic evaluations are so technically dependent and can easily take up to an hour to perform, many physicians shy away from doing these studies altogether. Failed outcomes can be the consequence. Often larger practices can find a clinician who is experienced with this work and is excited about creating a niche for themselves. More and more practices are outsourcing or contracting their urodynamic studies to experienced nurses and technicians. As with ultrasound, there are many courses out there if someone really wants to learn to be technically and professionally proficient. Recently a colleague so eloquently stated, “If you’ve seen one urodynamic, you’ve seen one urodynamic”. Training and experience do matter.
Again, a specific practice’s reimbursement for a urodynamic encounter will vary depending upon the actual procedure(s) performed (and documented) based on medical necessity and geographic location. Commercial payers do not always follow Medicare’s Correct Coding Initiative guidelines and payer contracts can vary. We are still seeing encouraging EOBs from commercial payers in early 2010. Finally, a $25,000 investment in urodynamic equipment, supplies, training, and promotion can still easily become a great service and a very good profit center in the right practice.
If you need further assistance in setting up urodynamics or coding or billing information you may call our PRS offices at 303-534-0574, ext. 123. We offer great solutions for many of your practice needs.
(Ted P Hammon is a key consultant with PRS-Consulting LLC and has over 20 years of hands on urology experience. Much of his clinical work has been specifically in urodynamics. If you feel that Ted or any of our consultants can assist your practice, do not hesitate to contact us.)
