A Full 2024 Explanation of Urodynamics Related CPT Codes

Urodynamics testing is the process of evaluating a range of bladder, urethra, and pelvic floor diagnostics. Accurate diagnosis of related health conditions requires careful examination of each component's very specific functions, and urodynamics testing includes numerous specific strategies for doing so.

Uroflowmetry is one component of this and is often considered the ideal way to check bladder function. Other diagnostic tools provide highly specialized and in-depth functionality testing. This includes diagnostics such as cystometry, urethral closure testing, electromyography, and video urodynamic tests. Each of these offers a very close look at a particular function level, offering an improved diagnostic evaluation.

Critical to urodynamics resting is appropriate billing and documentation. Because this is such an in-depth process and highly specialized area, accurate billing and documentation for urodynamics procedures is often confused.

Understanding Urodynamics CPT Codes

Regulatory coding practices are critical for all practitioners to apply. The U.S. Code of Federal Regulations (CFR) provides specific terminology to define various urodynamic measurement systems, which is done in 21 CFR 876.1620. The federal compliance rule applies to volume and pressure tools and also those that measure electrical muscle activity. More so, the terminology used includes the word "generic" to include other areas. Federal laws provide a very specific framework for governance and compliance.

Without accuracy in these areas, practitioners may find it impossible to receive reimbursement for their testing services. With all of these urodynamic procedures now available, doctors can gain better insight into diagnosing and treating conditions. However, it also complicates the process of accurately coding those medical procedures to ensure payment.

Providers must use different codes for each of the procedures they perform, even those that may seem very similar to each other. With numerous types of diagnostic measurement available, it can be very difficult for practitioners to accurately apply CPT codes to urodynamics testing to ensure absolute accuracy and compliance.

What are CPT codes?

Current procedural terminology (CPT) codes are those used in medical coding to streamline the reporting process, ensuring that there is an accurate description of the specific type of procedure provided. These codes are the preferred system for coding and describing all procedures and healthcare services provided.

Detailed Description of Urodynamics CPT Codes

Take a look at the following CPT codes specifically associated with urodynamics for a better explanation of when each should be utilized.

1. CPT Code 51726

Definition: Complex cystometrogram with or without calibrated electronic equipment.

Cystometrogram is used to evaluate detrusor contractions of bladder compliance. This method is used to measure post-voiding residual. It determines bladder capacity and detects detrusor sphincter dyssynergia (DSD).

This procedure uses calibrated electronic equipment to measure intra-abdominal, total bladder, and true detrusor pressures at the same time. This procedure aids in evaluating the storage only of the bladder. Normal results are expected in stress incontinence.

2. CPT Code 51727

Definition: Complex cystometrogram with urethral pressure profile studies (UPP).

Urethral pressure profile studies tests are only used in patients who have had inconclusive results from other tests. It is used to rule out severe urethral incompetence.

This test is a measurement of resting and dynamic pressures at the length of the urethra which are responsible for maintaining continence.

3. CPT Code 51728

Definition: Complex cystometrogram with voiding pressure studies (VP) with calibrated electronic equipment.

This voiding pressure study measures detrusor contractility and detects outlet pressure obstruction. This test is used in situations where the patient is unable to void.

4. CPT Code 51729

Definition: Complex cystometrogram with VP and UPP.

This test measures the contractility of the detrusor and detects outlet pressure obstruction. It is similar to 51728 but measures detrusor and urethral pressures at the same time while a person is voiding. This test helps to determine urodynamic obstructions.

5. CPT Code 51741

Definition: Complex uroflowmetry (UFR) with calibrated electronic equipment.

This code applies to the measurement of how much liquid a person excretes from the bladder. It measures this amount in cubic centimeters per second. The rate provided is the ratio of volume over time.

This measurement of the flow rate reflects the combined activity of the bladder neck, detrusor muscle, and the urethral function. In situations where a patient has poor detrusor function, this may lead to a decreased flow rate, and potentially inside neurologic lesions.

6. CPT Code 51784

Definition: Electromyography studies (EMG) of the anal or urethral sphincter, other than a needle.

This code applies to the electromyography study of the anal or urethral sphincter, any technique performed other than a needle. The needle electromyography study is done through code 51785. It is considered when there is concern about sphincter muscle functionality.

7. CPT Code 51792

Definition: Stimulus evoked response (e.g., measurement of bulbocavernosus reflex latency time).

This code refers, in limited applications, to the evaluated cases of suspected cauda equina syndrome. This application is not used often in practical urology. It is a stimulus evoked response. As per the AUA, this is a procedure that most typically is performed for erectile dysfunction and should not be billed at the time of urodynamic studies.

8. CPT Code 51772 and 51795

These codes were formerly used for Urodynamics but have been deleted. 

9. CPT Code 51797

Definition: Voiding pressure studies, intra-abdominal and intra-vesical.

This code is used for diagnostic testing that evaluates the detrusor muscle function. Specifically, it considers any component of intra-abdominal pressure in the bladder pressure voiding curve. This code is often used to rule out severe urethral incompetence in those who have had other inconclusive testing.

Urodynamics “-51” Modification

The "-51" modifier in medical billing indicates that multiple procedures were performed by the same provider during the same session. When applied to a CPT code, it signifies that additional procedures were carried out beyond the primary procedure.  -51 modification often applies when billing for urodynamics. Here are the key points regarding the "-51" modifier:

1. Multiple Procedures: The "-51" modifier is used when more than one surgical service or procedure is performed during the same operative session by the same physician or provider.
2. Reimbursement: The use of the "-51" modifier affects reimbursement rates. Typically, the primary procedure is reimbursed at 100% of the allowable fee, while subsequent procedures are reimbursed at a reduced rate, usually 50%. 
3. Order of Listing: When billing, the primary procedure (the one with the highest Relative Value Unit or RVU) is listed first without the modifier. The additional procedures are listed afterward with the "-51" modifier.
4. Documentation: Adequate documentation should be provided to justify the medical necessity of each procedure performed. This includes details of the procedures and the reasons for performing multiple procedures during the same session.
5. Exclusions: Some CPT codes are exempt from the "-51" modifier. These are typically identified by guidelines within the CPT manual or by payer-specific policies.

Here is a generic example to illustrate the use of the "-51" modifier:

• Primary Procedure: CPT code 12345 (Procedure A)
• Secondary Procedure: CPT code 67890-51 (Procedure B performed during the same session)

When performing a full urodynamics sequence of tests, you will often see 51741 and 51784 receive a “-51” modification.  For example, a patient with mixed incontinence and symptoms of OAB presents, and a urodynamics workup is ordered by the ordering physician.  In the testing the following procedures are performed and billed:  51729, 51797, 51784, and 51741.  When billed, 51741 and 51784 would both receive a “-51” modification, while the first two codes would not receive any modification.  It is important to note, that the payer (e.g. Medicare or private payers) will apply this modification automatically on their own. 

Split Billing and Global Billing for Urodynamics

In medical billing, "split billing" refers to the process of billing separately for the professional and technical components of a medical service. Split billing often applies to urodynamics.  These components are divided as follows:

Professional Component (PC):

This refers to the services provided by the healthcare professional, such as a physician or a radiologist, who interprets the results of a test or procedure.

The billing for this component is done using a modifier (usually modifier “26”) to indicate that only the professional services are being billed.

Technical Component (TC):

This includes the cost of the equipment, supplies, and technical staff involved in performing the test or procedure.

The billing for this component is done using a modifier (usually modifier “TC”) to indicate that only the technical services are being billed.

Split Billing Example

For a urodynamics study:

• The professional component would cover the interpretation of the urodynamic test results by a specialist, such as a urologist.  The date of the professional component would be the date the interpretation was completed. 
• The technical component would cover the use of urodynamic equipment, the supplies used during the test, and the technical staff who perform the procedure.  This is often performed by a specialist urodynamics nurse.    The date of the technical component would be the date on which the test was performed. 

When these components are billed separately, it allows for different entities to be reimbursed for their specific contributions to the service. For instance, a hospital might bill for the technical component while an independent urologist bills for the professional component.

Global Billing

Global billing refers to billing for both the professional and technical components together in a single claim.  This is typically done when both components are provided by the same entity or provider.  No specific modifiers are needed for global billing since the claim covers the entire service.  Urologists and urogynecologists that are performing urodynamics in their office and also interpreting the results typically bill “globally” for urodynamics. 

Comparison of Split Billing and Globally Billing:

Split Billing:

• Flexibility for providers: Different entities can bill for their respective services.
• Requires specific modifiers (26 for PC and TC for technical).
• Common in situations where services are provided by separate entities (e.g., a urologist interpreting a test conducted at a local hospital). Split billing can also be applicable if there is a material difference in time when the test is performed, and the results are interpreted.  For example, the test is performed on the 1^stof the month and the tests are not interpreted until the 20^th of the month. 

Global Billing:

• Simpler billing process when one entity provides both the professional and technical services.
• No need for modifiers as the billing is comprehensive.
• Often used by clinics or hospitals that handle all aspects of the service.
• For Urodynamics, global billing is more common than split billing.

Billing Urodynamics Under Advanced Practice Providers (APPs)

APPs often perform urodynamics testing, and there is a small nuance related to APPs.  If urodynamics are billed under an APP, there is a mandatory 15% reduction in the reimbursement rates when billing Medicare.  However, if the APP performed the work and the test is performed “incident to” the ordering physician and billed under the physician, then no reduction is applicable. 

Caveats and Best Practices in Urodynamics Billing

Accuracy is critical in the application of any CPT codes, including in the field of urodynamics. Some of the most common areas of noted concern include these:

• Pre-certifying: If you are new to urodynamics then it is critical to pre-certify each patient. Pre-certification helps to minimize denial of coverage. If your practice has been successfully billing for urodynamics for years, then pre-certification is likely not necessary if a given patient has not had urodynamics performed in the prior 12 months. If the patient has had urodynamics performed recently, then pre-certification is a good precaution. 
• Lack of documentation: Each CPT code billed must provide accuracy in documentation, which should include a separate report and interpretation for each of the tests performed.
• Inaccurate CMG code: CPT codes are always used, but the exact group of codes will vary, and if those do not match the testing exactly, that can lead to inaccuracies and denials of claims.
• Global Billing vs. Split Billing Decision: The choice between split billing and global billing depends on the structure of the healthcare service delivery and the structure of the legal entities involved. Split billing is useful when different providers are responsible for different components of a service, ensuring each provider is reimbursed appropriately. Global billing is more straightforward and is used when a single provider manages both the technical and professional aspects of a service. If your practice is performing the testing and your physicians are also interpreting the results, then global billing is the right option.  If you are part of a hospital system and you are performing the testing, and physicians part of a private practice are performing the interpretation then split billing is the right choice. 
• Order Matters: This may seem overly simple, but the ordering of the codes when remitting a claim to Medicare or private insurance companies does matter. Your billing software likely takes care of this automatically. Order the codes in the order from highest rate to lowest rate.  For example, you would bill the following four urodynamics codes in this order: 51728, 51797, 51784, then 5174. 

Thorough and precise documentation of every stage is critical. From initial screenings to testing and follow-through, ensure precise and thorough documentation of all elements to minimize the risk of denials.

Documentation Requirements for Urodynamics CPT Codes

Documentation requirements must be provided with all claims. Accuracy here is critical.

Note that the Centers for Medicare & Medicaid Services requires documentation for all codes to meet the following minimum requirements:

• Assessment of patient as relates to the complaint of the patient for that visit
• Relevant medical history
• Signed and dated office visit record or operative report
• Results of the pertinent tests and procedures

Final Thoughts

The importance of understanding and correctly applying urodynamic CPT codes cannot be understated. Not doing so can quickly lead to denials of coverage and payment due to simple errors. Brighter Health Network offers assistance with urodynamic billing.

Contact the BHN team for more information and assistance with billing for urodynamics. If you need help with a billing issue related to urodynamics, email us now at info@BHNCo.com. You can visit Brighter Health Network online now or contact us at 888-508-3330 for reliable help.