On this episode, Quantitative Urinalysis. Also, Modifier 58 on a Stentpull?

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Welcome to episode 309 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. And had a couple things come up as we're looking at all the topics and all what's going on. These were two things that have been questions that we've gotten in the last week or so. So we wanted to make sure that we're covering these topics to get you this information. So, Mark, let's tackle quantitative urinalysis first. What's going on there? Why is it why is it heating up? Or why has it already heated up, I guess?

Yeah, so there's a couple of things going on with quantitative UA. And there are a bunch of tests, let's just say test configurations that are out there, different groups that have come up with combinations of specific tests for urine that provide more data than a UA. And the way that they're coded typically is stack coding, meaning there are a bunch of individual CPT codes depending on what you're testing for, triatinine, protein, things like that. And it does provide some additional information, and there's been a couple of pieces of information that have come out that really talk about the value of this expanded urinalysis test. And one of the things that we're starting to see is what we saw originally with PCR testing, and that is that practices are implementing this new test, and they're essentially using it as a replacement for a standard UA, which ultimately is not going to be something that CMS is going to be happy about. So I wanted to raise the flag early. And don't want that to be at all interpreted here. But it does need to be selective as to when it's actually performed. I'm going to recommend that you develop protocols and procedures in your office for when a quantitative UA should be ordered instead of a UA or any other test that you're thinking about. The payers are already starting to react to this. We're seeing denials in the marketplace based on medical necessity for specific tests based on diagnosis codes. So that's your second thing that you've got to look at is different payers are setting up and moving rules around as to what diagnosis codes are there. It's kind of like LCAs or payer bulletins that are coming out. But the bottom line is before you even get to looking at what the payers are doing, you need to really consider what internally you're doing. Remember that most of our testing is not paid for because of its because it's screening. Just because you're a urologist does not mean you need all that inner additional information on every patient. So I'm going to highly encourage you to develop strong guidelines as to when a quantitative UA should be ordered. You want to have a reason why you're ordering that test. And maybe it's even after a UA gives you some indication of a positive. Different folks have taken different protocols. And certainly, if you have developed protocols, we'd be interested to hear about those. But want to make sure that you're using tests based on the number one rule for Medicare, and that is was the test medically necessary? And that's the biggest piece that you are going to have to justify. And it is going to have to be justified ultimately to a group of urologists and supported. So make sure that as you get into this and you start looking at this particular test option, that you have reasons for doing that test as compared to other options that are not as expensive or maybe even more expensive, but why that test for that patient? And make sure that everybody in the practice understands and documents to support those protocols that you set up.

All right, I got a question for you on that, but I'll hold my question. Ray, any comments, questions on that? No. All right. My question is when you're looking at the clinical pathways, and let's say the clinical pathway doesn't have a recommendation for or against quantitative urinalysis, you're saying when you build your protocol, you want to be able to back your thought process up with the medical necessity. And basically what you're saying is it's your role as a physician or urologist to make that argument for the medical necessity. And have you seen that being questioned at all?

So I'm going to go back again to PCR and what we're trying to do here. Basically, in the absence, so this is Medicare rules, and most of your other payers will at least lean into this. If there's not a clear payment policy, because we all know that payment policies aren't necessarily as broad as we would like them to be. And for that, you can look at sacral neuromodulation and all the stuff that's required versus the current Sufu pathway. So they don't always match. But if a payer sets up a rule, then unfortunately, at least at this point in time, we're generally going to have to follow that. Are there times when you can challenge through the medical necessity of the patient the actual payment protocols of the payer? Yeah, you can, but it's a tough road, right? So in the absence of a policy, the fallback position is the service needs to be proven as medically necessary. So ultimately, if you have peer-reviewed studies that really indicate when the tests should be performed or why the tests should be performed, and you can back into when. Those are the things that you want to build into your own clinical pathways. And you said pathways. I think you're talking about the official guidelines for treatment of disease states that are published, may not have this particular item recommended, or maybe it's on there, but it's not strongly recommended. So the payers are fighting against you. So you want to build your best case. You want to make sure that case is clearly communicated to your clinical team, and that your documentation supports that that case or those circumstances are there. And as we all know, patient care boils down to individual patients. So the guidelines, the pathways, all of those things are and should include some off-ramps, some considerations to let the clinical judgment occur for that physician or that QHP, the APP in in some cases. But it does need to be fairly guided in that decision-making process, especially when you're talking about a differential from a payment perspective, and the payer can easily come in and say, you're doing this for money, not for the clinical value. And that's the argument they're going to start with. So you start off in the court of the payer as guilty and have to prove your innocence with your documentation. So it's not a typical court of law, it's the payer's payment court. So you got to build that way, you got to think that way.

Ray? Anything to add?

Well, Mark, it sounds like you're saying to start with the doc ought to start with the medical necessity of that test with that patient. And if the medical necessity is there in your mind, then you need to be sure that your colleagues agree with you for any publications, pathways, etc. And if the medical necessity is there, then you've got to take a look at the payer pathway to get paid. What do they have as far as diagnosis that you have to meet? And then you have to adjust your diagnosis to meet the criteria of the payer.

So the one thing on that that pathway that you said was adjust your diagnosis to meet the payer. If the patient doesn't have the diagnosis, don't put the diagnosis on there by any means. Like make sure that the that ultimately your definition of medical necessity may not meet the payer's definition. And you can't manufacture that. So don't take that as just flip the diagnoses to get paid. What you need to do is understand the parameters. And does your patient meet those parameters? And does my documentation support those parameters? So yeah, so I think you are leading into the right way, but I think it came out wrong. Yeah.

So that's the problem with dealing with an aging mind. Sometimes things don't come out the way you want them to. I never would have suggested changing the diagnosis. But I was talking about modifying your verbiage so that your documentation satisfies the diagnosis that you've already put on that fits the payers. But if it doesn't fit the payers, why you'll you're gonna have to appeal.

Yeah. Yeah. So, and that's and I think, yeah, and I'll put one more clarifier on there. I think what you're saying is you're running that test because the patient has that diagnostic problem. So you absolutely on the billing side want to make sure that your billing team, and this is why the wheel of fortune that you came up with so many years ago is important. So that I ideally the clinician would assign the right diagnosis to the right codes based on the patient's presenting problem. But you may have to have your back-end RCM team reorder the diagnoses based on the CPT codes. But if they're not in the record, nobody can do that. So make sure that you're accurately and adequately reflecting the patient condition so that you are, in fact, following your own guidelines and matching the payers' guidelines or understanding that the payers maybe not going to pay for this test, even though you think it's the right thing.

All right. Okay, well, let's move on to our second question. Our second qu the second topic we wanted to cover was and that's been coming up is using a modifier 58 with a stent pull. So, Mark, what's going on with that and why is that becoming an issue?

Well, so this is every once in a while somebody pokes you with a question, and they have come up with a small snippet of a rule somewhere, and they flop that into you, and I have to, it's like, oh man, I need to go back and double check. Has something changed? And we do stay on top of everything, but things get missed on occasion. But we got the question specifically from someone the basic question overall was the 58 modifier is for a I think it was for a more extensive procedure in a post-operative global that's not a part of the standard of care. And ultimately that whole question was targeted at so I would think that if I did a stint removal on a patient in every single case, that it's standard of care, and I shouldn't be able to bill the stent removal. And so ultimately I'm like, okay, I can see where the question is coming from there with that. So I went back once again and looked at the definitions in the carrier's manuals for the 58 modifier and for the global. So just a reminder, the 58 modifier was established to facilitate billing of staged or related surgical procedures done during the post-operative period of the first procedure. It's not used to treat the or report the treatment of a problem that requires a return to the operating room. That's where we use the 78 modifier. And the physician may need to indicate that the performance of a procedure or service during the operative period was planned prospectively at the time of the original procedure, or B was more extensive than the original, or it was for therapy following a diagnostic surgical procedure. So we've got three different circumstances. And we also go look at the package for the global. And I'm gonna not give you the whole thing, but the things that are included in the global in the post-operative period are complications following the surgery, all additional medical or surgical services required by the surgeon during the postoperative period of the surgery because of a complication, which do not require additional trips to the operating room are included, post-operative visits during the postoperative period for the surgery that are related to recovery from the surgery, postoperative pain management by the surgeon, supplies except for some specific exclusion, and this is the big one, miscellaneous services, items such as dressing changes, local incisional care, removal of the operative pack, removal of cutaneous searches and staples, lines, wires, tubes, drains, casts, and splints, insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric, gastric, nasogastric and rectal tubes, and changes and removal of trach tubes. So those are all included. What's not included, and again I'm skipping a lot, are clearly distinct, and this is not included, clearly distinct surgical procedures during the postoperative period, which are not reoperations or treatment for complications. A new postoperative begins after the subsequent procedure. That's if it's uh treatment of something that's unrelated. This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. So what's that saying, what that's saying is that before the surgery, because of a medically necessary reason, the physician in this case elects to place a stent. It's not a urinary catheter, it's a stent. It is indwelling, and it may be placed because of potential damage to the ureter, the size of remaining fragments. So there are various reasons they could put that in. Maybe there's a small stricture or some uret ureter physiology that they want to protect to allow all the stones to pass. And they decide not to leave the string extruding because they're worried about infection or patient compliance, all those things. And so they plan ahead of time, or as the procedure's being done, that they need to remove or place a stent, and they're gonna have to remove it with a cystoscope and a grasper. So that is a staged procedure in the care of that patient, which is where that 58 modifier fits. But that also means that documentation has to support the medical necessity and the staging of that particular service.

Ray? Comment, question? Nope, nope, that was good discussion. So my only question is where do you put the 58 modifier? Which when do you put it on there and how do you document that? So if you're billing it, does a 58 modifier go on both procedures, just the first one, just the second one, or what? Second one, the one that's in the global. All right. And but you have to put your documentation in the operative note of the first one.

Either in the operative note of the first one, or well, it's a good idea to put it in the second one. Should be in the first one, or it can be then the pre-operative note. You know, based on the the size of the zone, we plan to place a stent, and we are going to place it in a way that's gonna require removal. So put that in preoperatively based on what you find, and that could be all right, we did the initial, we positioned the patient. Now we know this is a little bit big. That's pr that's planned. So make sure it's planned for that second step.

All right. Okay, well, that's all we have for today's episode. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com forward slash PRS network for specials for our listening audience. All right, let's get some final thoughts. Mark, final thoughts today.

Yeah, so one, as always, documentation. Pay attention. Understand what needs to be documented and continue to work with everybody. And I'm gonna tell you that protocols, procedures, pathways, understanding all this stuff and having these things written down are important steps towards actually leveraging AI. Don't count on artificial intelligence to do this for you. And that is where we're seeing lots of failures as people are implementing AI in different parts of their practice. So it's important to have your protocols up and running and adhered to before you can really trust the AI to help you out. And again, I will go back to the team. The team needs to understand what's going on and building double checks to make sure that everybody in their very busy, very overloaded pathway right now has clear directives, clear checklists, those types of things that you can build correctly, document well so that when your records are reviewed, you're ready.

Yeah, and that's where AI can help too, is helping to start build those, building those check those checklists and pathways and that kind of thing. As long as you get them. Yeah. But and I was gonna add, but you need that human in the loop to review that. You can't just put them in place. You need to make sure it says what you want. Yeah. Ray, final thoughts.

No, I think that the you said it all. You've got to have that human in the loop, and you've got to have your protocols to fit what you need.

All right. Well, that's all we have for today. Thank you all for listening. Take a doubt, Ray.

Happy coding and documentation.

Thank you for listening to the Urology Coding and Reimbursement Podcast, where we help urologists and their staff maximize income and efficiency so there's time and energy for patient care and a happy life. Special thanks to Carol Painter for the music today. You can find his music on Spotify under his record label New Twitter