When is an evaluation and management (E/M) service billable and when is it not billable on the same day as a medical or surgical procedure? This is an excellent question, and the answer requires an understanding of what is included when a procedural service is valued. As we remember, all procedures, from as seemingly small as an intramuscular injection or urinary catheter placement to as large as the most intensive and invasive major surgical procedure, have a global period associated with it. The global period defines the typical service and work performed and included (and therefore already paid) and therefore also defines what can (and what cannot) be reported concomitantly. It would be wrong to bill twice for the same service, which is called double billing.

The global period (and therefore payment) typically includes all of the work that occurs to perform a service. This includes the same-day pre-service patient evaluation (such as whatever is need to “clear” the patient and prepare the patient for the procedure), obtaining patient consent, marking the patient, writing orders, bringing the patient to the site of service, positioning the patient, prepping and draping the patient, administering anesthesia if needed (if performed by the same provider), performing the intraoperative work itself, and completing the postoperative work associated with the procedure. For 0-day global procedures the global payment includes all typical work performed on the same day of the procedure (the day of the procedure itself is considered day zero), while in the case of 10-day and 90-day global procedures the work also includes all of the work (including hospital and office-based work and visits) within the number of days in the postoperative period. Therefore, based upon an understanding of what is already included in a global period payment, one can then determine if other services are reportable. One should only report those services that are truly separate and identifiable.

When it comes to reporting an E/M code on the same day as a procedure, a modifier is typically placed onto the E/M code as communication to the insurer of the exception to the rule. For example, Modifier 25 describes a “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.” Please note that Modifier 25 is easily audited. There have been a number of instances when a urologist or urology group has been investigated and audited for their use of this modifier, some of which have been accused of violation of the False Claims Act. To help guide one for appropriate (and inappropriate use) of Modifier 25, some urology examples are described below.

Example 1: Scheduled Injection

A patient presents to the office for a scheduled bladder Bacillus Calmette-Guérin instillation. The physician or other qualified health care professional sees and examines the patient, discusses the patient’s current symptoms and plans, checks the urine analysis to prove absence of infection, and determines that the patient is safe to receive the medication. Consent is obtained. The patient is positioned, prepped, and the medication is instilled. The patient is given their discharge instructions. The plan for the next instillation(s) and plan including follow-up cystoscopy is re-reviewed.

Coding: Current Procedural Terminology (CPT) code 51720 Bladder instillation of anticarcinogenic agent (including retention time).

Discussion: In this case CPT code 51720 should be reported, but no other E/M service should additionally be reported. E/M services inherent to the procedure are already accounted for as part of the valuation of the CPT code and should not be reported separately. CPT code 51720 is a 0-day global procedure, and therefore the services included in the code include the pre-procedure evaluation, consent, positioning, instillation, and post-procedural care. Other 0-day global procedures that are commonly performed in the office setting and are pre-planned, such as, intramuscular injection (for instance, hormone agents), posterior tibial nerve stimulation, urinary catheter placement or exchanges (CPT codes 51701, 51702, 51703, 51705), and urodynamics, would follow the same rules.

Example 2: Scheduled Injections With New Unrelated Symptoms

A patient presents for routine suprapubic tube exchange. During the visit the patient admits to new onset of right-sided flank pain and low-grade fevers and admits to a history of kidney stones and recurrent urinary tract infections. The provider sends the urine for culture, starts empiric antibiotics, and sends the patient for both bloodwork and a CT scan to evaluate for kidney stones or pyelonephritis.

Coding: CPT code 51705 Change of cystostomy tube; simple and established patient E/M code (appended with Modifier 25, based upon insurer).

Discussion: New symptoms and concerns for kidney stones or pyelonephritis are clearly a separate and identifiable reason for visit from the suprapubic tube exchange and therefore an appropriate E/M code should be reported in addition to the CPT code.

Example 3: Cystoscopy for Microscopic Hematuria Evaluation

A patient presents for cystoscopy for microscopic hematuria evaluation. The cystoscopy appears to be normal and a urinary cytology is sent. The provider sits down to discuss these findings and the results of the CT urogram with the patient to create a follow-up plan.

Coding: CPT code 52000 Cystourethroscopy (separate procedure).

Discussion: The CPT code for cystoscopy should be reported, but no E/M code should additionally be reported. Per the Medicare Claims Processing Manual (Chapter 12, Section 40.1, C), “Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.” The associated E/M of the cystoscopy is included in the valuation of the code itself, which includes the pre-procedure and post-procedure work. There is no separate and identifiable diagnosis or work being performed to justify reporting an E/M code on the same date.

Example 4: Cystoscopy for Microscopic Hematuria Evaluation With New Finding

A patient presents for cystoscopy for microscopic hematuria evaluation. Cystoscopy reveals a 3 cm right lateral wall bladder tumor. After the cystoscopy the patient is counseled on this new finding and the plan is discussed, along with a discussion about the risks of bladder tumor resection.

Coding: CPT code 52000 Cystourethroscopy (separate procedure) plus an established patient E/M code (appended with Modifier 25, based upon insurer).

Discussion: In addition to the CPT code for cystoscopy for the microscopic hematuria evaluation, it would be appropriate to report an E/M code for a discussion of a new finding of a bladder tumor, which is clearly a separate and identifiable diagnosis from the reason for the visit initially.