UCR 020: FAQs - Modifier -57 vs Modifier -25

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UCR 20: FAQs - Question about D40.0, Neoplasm uncertain behavior of prostate? Modifier -57 v Modifier -25?

August 24, 2020

Mark, Ray and Scott answer 3 questions from the Urology Coding and Reimbursement Group

Scenario:
New patient being seen via telemedicine for the first visit. Dr. has ER reports and a CT with finding of "a nodular mass-like extension from the left posterior aspect of the prostate into the seminal vesicle and an impression of "Probable prostate cancer extending into the left seminal vesicle". A PSA was done and came back at 950.0 ng/mL. At the time of the Trusp/Bx, Dr coded D40.0, Neoplasm uncertain behavior of prostate. The physical findings at the biopsy were "Large, nodular hypoecoic mass left base & mid-gland of prostate". I think Dr. was trying to show that he didn't have pathology to prove malignant neoplasm and since there isn't an "Unspecified neoplasm" for prostate, I think he should just code what he knows for sure.....nodular prostate and elevated PSA......possibly also use N42.9 Disorder of prostate, unspecified which means anything from an abnormal prostate on exam to cancer. Could N42.9 be used as the "neoplasm of prostate, unspecified behavior"??
Hi, dr did a laparoscopic radical nephroureterectomy for ureteral cancinoma and also a repair of a lumbar hernia
i came up with 50548 for the nephroureterectomy but am unsure of the hernia
thanks
Can you clear up when to use modifier -57 and modifier -25?

Is -57 for clinic AND hospital consults? Does the surgery you are planning for the same day have to be a surgery with 90d global? what if it's just ureteroscopy? Does putting in a catheter after an ER consult need a -57 modifier?

Is -25 used for separate E/M ONLY if they have a separate procedure? (for instance come in for cysto but then mention a genital wart that is then removed) Or can you add -25 for a totally unrelated problem that requires medicine or counseling but no procedure (for instance come in for cysto and then mention ED and discuss options/prescribe viagra)