2018 Payment Policy for Blue Light Cystoscopy
In the 2018 Outpatient Prospective Payment System (OPPS) final rule, the Centers for Medicare & Medicaid Services (CMS) finalized their proposal, without modification, to allow for a complexity adjustment when blue light cystoscopy is reported on the same claim as certain cystourethroscopy CPT codes.
Traditionally, CMS explains in the final rule, white light (or standard) cystoscopy, typically performed by urologists, has been the gold standard for diagnosing bladder cancer. Enhanced bladder cancer diagnostics, such as narrow band imaging or blue light cystoscopy, increase tumor detection in nonmuscle invasive bladder cancer over white light cystoscopy alone, thus enabling more precise tumor removal by the urologist.
Blue light cystoscopy can only be performed after performance of white light cystoscopy. Because blue light cystoscopy requires specialized imaging equipment to view cellular uptake of the dye that is not otherwise used in white light cystoscopy procedures, some practitioners consider blue light cystoscopy to be a distinct and adjunctive procedure to white light cystoscopy.
The current CPT coding structure for cystoscopy procedures does not identify blue light cystoscopy in the coding descriptions separate from white light cystoscopy. Therefore, the existing cystoscopy CPT codes do not distinguish cystoscopy procedures involving only white light cystoscopy from those involving both white and blue light cystoscopy, which require additional resources compared to white light cystoscopy alone.
CMS determined that blue light cystoscopy represents an additional elective but distinguishable service as compared to white light cystoscopy that, in some cases, may allow greater detection of bladder tumors in beneficiaries relative to white light cystoscopy alone. Given the additional equipment, supplies, operating room time, and other resources required to perform blue light cystoscopy in addition to white light cystoscopy, for 2018, CMS created a new HCPCS Level II C-code to describe blue light cystoscopy and to allow for a complexity adjustment to APC 5374 (Level 4 Urology and Related Services) for certain code combinations in APC 5373 (Level 3 Urology and Related Services).
Coding for 2018
The code pair combination of procedures described by new HCPCS Level II code C9738 Adjunctive blue light cystoscopy with fluorescent imaging agent (List separately in addition to code for primary procedure) and cystoscopy procedures assigned to APC 5373 are now eligible for a complexity adjustment.
The CPT codes are:
52204 Cystourethroscopy, with biopsy(s)
52214 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands
52224 Cyustourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy
Whereas the code pair combination of HCPCS Level II code C9738 with CPT code 52204, 52214, or 52224 will qualify for a complexity adjusted payment from APC 5373 to APC 5374, the combination of procedures described by new HCPCS Level II code C9738 and cystoscopy procedures assigned to APC 5374 and APC 5375 do not qualify for a complexity adjustment.
CMS plans to track the utilization and costs associated with white light/blue light cystoscopy procedure combinations that will receive a complexity adjustment.