Key takeaways from this episode

• For a two-hour resectoscope evacuation of a bladder full of organized clot, bill 52001 with modifier 22. The 52001 descriptor (cystourethroscopy with irrigation and evacuation of multiple obstructing clots) does not restrict the method, so resecting the clot and removing the pieces with rigid biopsy forceps still fits; document the extra time and instrumentation to support the 22 and put a price on it.
• Two defensible alternatives exist, but neither is clearly better. 52315 (removal of foreign body, complicated) with modifier 22 pays only slightly more than 52001, and unlisted 53899 with a resection comparison is not fraudulent, but it is hard to walk away from a code that essentially describes what was done.
• The facility lands in APC 5374 either way. 52001, 52234 and 52315 all group to APC 5374, and an unlisted code has no APC assigned, which takes some of the air out of the unlisted argument. Your documentation should still help the facility get paid.
• A pre-op H&P done outside the global period is billable with a Z01.81x code listed first. Use Z01.818 (encounter for other preprocedural examination), or Z01.810 for a cardiovascular, Z01.811 for a respiratory, or Z01.812 for a laboratory preprocedural exam. The global starts the day before a 90-day procedure and the day of a 0- or 10-day procedure; an H&P inside that window is bundled.
• The decision-for-surgery visit gets the disease diagnosis, not Z01.81x. If the visit 30 days earlier is where the surgery was decided, bill it with the diagnosis for the problem being treated and no modifier.
• Expect payer variation on pre-op visits. Some payers imply a longer global and deny the Z01.81x visit as preoperative, and Medicare Advantage plans must cover at least what Medicare covers but have some flexibility in how they interpret the global period.
• Modifier 57 is only for 90-day global procedures; the OR and anesthesia are irrelevant. Medicare includes the decision for surgery in 0- and 10-day globals, so a same-day E/M with a cysto, stent or clot evacuation needs modifier 25 and an E/M the day before needs no modifier; for a 90-day global use 57 the day before or day of (25 also works the day of if the visit was for a different problem).
• Modifier 25 requires a significant, separately identifiable E/M. A same-day H&P for a procedure you have already decided to do is not separately billable unless that visit is the first time you saw the patient and made the decision.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 253, recorded July 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Coding a two-hour resectoscope clot evacuation

[00:00] Scott Painter: On this episode: billing for the removal of a large clot, and E/M services before a surgery. Stay tuned. Welcome to episode 253 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. We have some questions that came into the PRS help desk that we want to answer. As I mentioned in the intro, the first one is a difficult clot in the bladder. I'll go ahead and read the question, and let's see if we can get some answers.

Nancy has a question. This is in the state of Nevada, from Anthem Blue Cross Blue Shield, and her question is: I'm looking for a CPT code for transurethral resection of a bladder clot that was organized, to facilitate removal. Patient was inpatient, and the doctor tried to do a clot removal from the bladder but was unsuccessful, as the whole bladder was the clot. He used a resectoscope to resect the clot into smaller pieces and then removed them with a rigid biopsy forceps. The procedure took over two hours. I need help with a procedure code that will accurately describe this procedure. All right, what do you got, Mark?

Mark Painter: Well, first I'll say that was easy for you to say. This is definitely an interesting one, and I can understand the question. We actually had a bit of a discussion on this one. Obviously, the code 52001 is what we think of first, which is cystourethroscopy with irrigation and evacuation of multiple obstructing clots. That kind of describes what was done, and modifier 22 might be the right answer for this one. Now, we did try and look around to see if there was something else that might fit, because this was a big clot. We did use a resectoscope, and typically that is not the method that would be used for a standard clot evacuation. But in the end, it is a clot evacuation, and there is no restriction in the description that talks about whether or not there had to be a resectoscope, or there needed to be biopsy forceps, any of those things. It's about evacuating the clot, and you could almost imply any method there.

But we did take a look at the potential of 52315, which is the removal of a foreign body, complicated. That was one option we considered. The other way would be to go for the unlisted code, because indeed we did use something totally different. But in the end I circle back around to: probably the right coding move is 52001 with a 22, and make sure you put that price in and your documentation in to get that support. The other two methods, certainly, I don't think it's a hundred percent wrong to look at the removal of the foreign body. Again, there's nothing in there about the resectoscope or the biopsy forceps, and it only pays slightly more than the 52001. And I'm leaning against the unlisted code because the 52001 is really what you did, in general terms: evacuate multiple obstructing clots that were all stuck together. So it's a tough call, but I think in the end the 52001 with the 22 is probably the right move. But I do think you could look at those other two options, either the unlisted, the 53899, or the 52315 with a 22.

Scott: Ray, questions, comments?

Dr. Ray Painter: Yes. In the end, I agreed with Mark, but I would say that if you decide you want to get their attention with the 22 modifier, because what was done was a lot more, and the instruments required by the OR were a lot greater than just irrigating a clot, use some codes that really reflect a resection and a high amount of time. And given the fact that you did do a resection of clots and you did do evacuation of clots, I don't think it would be fraudulent to use the unlisted code and do a comparable to a resection as well as charging the evacuation of clots. But in the end, we all came around to the 22 on the evacuation of clots, because that's really what you did.

Scott: Agreed. And I do want to add one of the comments that came up when we were discussing this. I think Ray made it, something to the effect that it's hard to go away from a code that pretty much describes what you have done. Even though the 52001 doesn't encompass all of what was done, and that is the argument for the 22 modifier, it does pretty much describe what was happening in the procedure.

The facility side: APC groupers and the unlisted option

[06:00] Mark: Yeah, and I should add, Ray brought up the resectoscope and some of those things. Ultimately, the APC grouper for the 52001 is 5374, which is the same grouper that the 52234 is in. So I think the facility is kind of stuck in that same grouper regardless of which direction you went, with the 52315 or the 52001. And that is one of the drawbacks to using an unlisted code: there is no group assigned to the unlisted codes.

Scott: And the facility just has to accept the fact that they used additional instruments for this particular procedure and move on. Is that kind of it? I know we're not covering facility coding here in detail, but that's kind of the way it works with the groupers.

[07:00] Mark: It is the way the groupers package things across multiple procedures. So that's kind of where we're stuck with that APC.

Ray: Well, if that doesn't help the facility, it probably takes the air out of my argument for an unlisted.

Mark: It was a good thought, though.

Ray: All right. And Scott, we are responsible for doing documentation that helps the facility do what they need to do to get paid as well.

Scott: Very true.

Ray: That's part of our job.

Billing an updated H&P before surgery

Scott: Yep. Okay. Let's move on to the next question we had. This question came in from Irene, and Irene asked: Do you have a prior podcast on billing, or information on billing, for an updated H&P prior to surgery, if the prior H&P was done greater than 30 days before the surgery? Appreciate the help. All right. Instead of referring to another podcast, and I'm sure we've talked about this at some point, we wanted to cover this again. It also ties in with our last question as well, but why don't we start with this, and then we can tie in the last question.

Mark: So when we look at a preoperative H&P, the H&P is really a part of the global as it's defined. But we also have the global definition, which is really based on a timeframe. One day prior to a 90-day global, the global period starts, and for a zero- or 10-day global, the global period starts the day of. So if a service is provided outside of that global, we do have a way to indicate that it was preoperative. We can use our appropriate ICD-10 code, the Z01.818, which is encounter for other preprocedural examination, or if they have additional problems, the Z01.810 is for a cardiovascular exam, .811 is for a preoperative respiratory exam, and .812 is for a laboratory exam. So we do have some variation there in that preprocedural visit indicator, which should be your first ICD-10 assigned to that particular CPT code. The payer may or may not, with that service outside the global, try and include that visit.

The first visit, the one that was done 30 days before the procedure, was really not part of the global. Did you bill that? Hopefully that was part of the process of making the decision to go to surgery, and you went ahead and did the H&P, and you could bill for that visit without a modifier, because you're not in the global period. If the second visit occurred the day before a 90-day global, we can't bill that, or the day of a zero- or 10-day global, we don't have a way to bill for that particular visit. It really is bundled. So you've got to look at those surrounding circumstances in order to get to your conclusion on whether or not to bill it. But the diagnosis code, if it purely is preoperative, does need to be reflective of the reason for the visit, and that's that Z01.81, pick your last digit, ICD-10 code.

Payer variation and Medicare Advantage global rules

[11:00] Scott: Have you had any trouble with payers paying for that Z01.81 series?

Mark: We have. There are definitely some payers that imply a global for longer periods of time. They will deny as preoperative. There are some others that will say it's included regardless of the timeframe. So it is one of those that varies as far as how the payers assign those rules.

Scott: If you're outside the global and you make a decision for surgery and you do the H&P, you wouldn't put that Z01.81 on there.

Mark: Correct. You would not. That was really the visit in which you decided to do surgery. You were dealing with the disease state, the reason you're going to do the procedure, so that would be a different diagnosis code, depending on what the problem was.

[12:00] Scott: Ray, your comments, questions?

Ray: I think that's good. And Mark, you mentioned the payers being different. Medicare carriers themselves have to stick with the rules that you have outlined, and private payers get to do anything they want to do and can get away with in the contract you signed. But what about Medicare Advantage? Do they have the option of changing the global days?

Mark: They have to cover at least what Medicare does. So in those rules, there is probably some flexibility in the interpretation of that global period. So the carriers that are in the Medicare Advantage plan would in fact have some ability to handle that differently than Medicare.

Modifier 25 versus 57: it's about the global, not the anesthesia

Scott: Okay, let's continue this discussion with our next question. The next question came from Irena, and the question was kind of a 57 versus 25 modifier. I'll read the question, and then, Mark, I think you probably want to reframe the question a little bit, but we'll start with this. When is it best to use the 25 versus the 57 for a same-day procedure? I thought anything requiring anesthesia would be an OR procedure (cysto, stent, clot evacuation, et cetera) and would be a 57. But is 25 more appropriate even if done in the OR? Okay, Mark.

[14:00] Mark: Let's go back to the definition of 25 and then 57, and then we have to dive into the rules from a Medicare standpoint that define a global. The first thing is, modifier 25 is a significant, separately identifiable E/M service on the same day as a procedure. Modifier 57 is the decision for surgery. So they have slightly different definitions as to their overall utility relative to this particular circumstance, and really across the board.

Now, when we look at Medicare, Medicare has specifically stated in their definition of a global that minor procedures, those procedures that are defined by a zero- or 10-day global, include the decision for surgery. Which means Medicare does not allow modifier 57 to pull an E/M for a same-day E/M service provided with a zero- or 10-day global. So it's not really about the OR or anesthesia; it's about the global, and how that definition is different than a major procedure, which is any procedure with a 90-day global. The 90-day global does not include the decision for surgery, and therefore the 57 can be used on an E/M service provided either the day before or the day of the procedure. The 25 modifier can be used on the same day as a 90-day global procedure, but a lot of people find it easier to focus on the globals and use those modifiers. The most appropriate modifier would be the 25 on the same day as a 90-day global procedure if the E/M service was done for some different issue. If it was in fact a visit that resulted in the decision for surgery, then the modifier 57 is appropriate. The day before the procedure, we're going to have to use the 57. The modifier 25 does not extend to the day before.

So a piece of that choice is based on timing: when was the E/M service done, the day before or the day of? The second piece of that choice is what was the reason for that visit, and the reason it should be allowed within the global period. That documentation needs to be there to support it. And the third thing, and I think really what Irena is asking, is: is a procedure a procedure because it has anesthesia, and you need a modifier? The answer to that is no. It's based on the global. So for a 90-day global, you can use a 57 the day before or the day of. For a zero- or 10-day global, you cannot use the 57. That has to be modifier 25 for Medicare. Some of your other payers may allow 57, but typically your larger payers tend to follow Medicare in this regard.

Scott: Ray, your comments.

Ray: Well, in the question they didn't mention anything about an E/M service, but we have assumed, as Mark discussed, that they were talking about an E/M service on the same day as a procedure, because 25 and 57 are only used, and only recognized, if you use them on an E/M service.

Scott: Good point. Can you give us an example of a 57, like with a vasectomy, and a 25 with a cysto?

Mark: So that's a zero global.

Scott: Whereas 25 would be used on the cysto. If you were seeing the patient and you decided to do the cysto at the time of the visit, you would then use the 25 modifier. Is that correct?

Mark: Correct. That is correct. And she had asked specifically about cysto stent, cysto clot evacuation, et cetera. Those are all zero globals, so that would be a modifier 25 for a same-day E/M. And for an E/M provided the day before, no modifier would be required.

Sponsor and the PRS Coding and Reimbursement Hub

[19:00] Scott: All right, Ray, anything else? Nothing. Okay. Well, let's wrap this episode up here. 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/prsnetwork for specials for our listening audience. We also want to remind you that the PRS Coding and Reimbursement Hub is available for your review. You can go to prsnetwork.com/urologyhub, and you can check it out. I think we have three different categories live right now, and we're going to be adding more and more, and we'll be announcing that every podcast, just to make sure that you're aware of it. This is a quick place for you to go for information on coding categories like urodynamics or kidney stones. And then, as we build this out, we'll be having specific pharmaceuticals and medical devices with their coding and reimbursement strategies and information on those particular products. So keep an eye out for that. We'll keep letting you know when that is updated throughout the rest of the year. All right, let's get some final thoughts. Mark, your final thoughts.

Final thoughts

Mark: First, with the clot evacuation, that was a good question and a tough one, and that really shows where we drive off the CPT description and we're kind of stuck with some things, I think, in the overall process. That's one of those areas where you win some, you lose some, based on the RVUs that are established. And then, as far as looking at the E/M services surrounding global periods, that discussion keeps coming up. In the end, you really need to look at both the global definition and the modifier definition to use those appropriately. And although there is some payer variation, we've pretty much seen most of the payers settle in on what Medicare is using at this point in time: the zero- and 10-day globals requiring that modifier 25 for same-day E/Ms, and for the 90-day globals, the day before, modifier 57; the day of, technically 57 or 25 will work, but if it's the decision-for-surgery visit, as in most cases, the 57 would be the appropriate modifier to get your E/M paid with that 90-day global. Ray, final thoughts?

Ray: The one thing we should mention in this discussion is, with the 25, if the E/M service provided on the day of the service is related to a procedure you've already decided you're going to do, and it's to do an H&P or anything else, you can't use it, because the definition is a significant and separate service provided. So if it's related to the procedure, unless that's the first time you've seen the patient and decided to do the procedure, then you should not use it.

Mark: All right.

Scott: Okay, let's end this episode here. Thank you all for listening. Take us out, Ray.

Ray: Happy coding.

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