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    T pellets: What are you allowed to charge?

    Services beyond implantation must be ‘separately identifiable,’ ‘significant’ to justify modifier


    The second criterion necessary to justify use of the –25 modifier is “significance.” That means if you review a lab test in passing and said, “Yes, we’re OK to go,” that’s not significant. The encounter would be “significant” if the medically necessary, separately identifiable service required additional time and effort. For example, if a patient was seen in the office, diagnosed with hypogonadism, and scheduled for the pellet implantation a few weeks later, it probably isn’t medically necessary to reevaluate the disease process on the day of implantation and therefore you should not charge an E&M code.

    Also see - ICD-10 phase II: What you should be doing now

    However, if a patient is returning 3 to 4 months after the first injection and you review previously ordered lab work, obtain history to assess the patient’s clinical response, and spend time in medical decision-making to adjust the number of pellets to be given, you have clearly provided a medically necessary service that is separately identifiable from the procedure and was significant. The encounter should be charged with the –25 modifier.


    My doc did a cystoscopy with stent removal through the stoma in a patient with an ileal loop. Should I code using an unlisted code, or should I use a regular cystoscopy? I have not come across this before.

    Your question is very timely. In the past, some would’ve answered the question with, “You should use a small bowel endoscopy code.” However, CPT has clarified the rules in writing. We’ve now been given permission (empowered) to use the regular cystoscopy codes for all endoscopy procedures performed on replacement bladders. The change will make it much easier to report a number of the endoscopy procedures.

    Therefore, you should report the procedure with 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple).

    More from the Painters:

    Is modifier –22 an option for multiple stones?

    Today’s billing process: Follow these 11 steps

    Four decades of billing, collections: How times have changed

    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.

    Subscribe to Urology Times to get monthly news from the leading news source for urologists.

    Ray Painter, MD
    Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and ...
    Mark Painter
    Mark Painter is CEO of PRS Urology SC in Denver.


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