I am confused about billing for post-op voiding trial following transurethral resection of the prostate a week later in the office. Op note states the patient will return in a week for cath removal, and a week later he comes in and does a voiding trial. Would this be considered part of the global period, or should it be billed with a –58 modifier? I can’t seem to find definitive guidance on this anywhere.
CPT 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) is assigned a 90-day global by Medicare. A 90-day global procedure means that the work for the procedure and associated care has already been factored into the payment for the code, typically including 1 day preoperative work, work on the day of the procedure, and the work that is typical for 90 days beginning the day after surgery.
Medicare has further defined work to include complications that do not require additional trips to the operating room, (all) follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery, post-surgical pain management by the surgeon, supplies (except for those identified as exclusions), and miscellaneous services such as dressing changes; local incision care; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; and insertion, irrigation, and removal of urinary catheters.
Therefore, removal of the Foley catheter is specifically included. The insertion of a replacement catheter, if the patient is unable to void, is also part of the global and not paid separately unless the insertion requires a return to the operating room (highly unlikely).