Urology Coding Alert

Medicare and some commercial payers will pay for multiple procedures used to reconstruct the pelvic floor. A clear understanding of these procedures, of their relationships to each other, and of Medicare bundling rules is necessary for proper coding and ethical reimbursement. Case study: The patient's preoperative diagnosis includes stress urinary incontinence (ICD9 625.6, Stress incontinence, female), vaginal prolapse (ICD9 618.5, Prolapse of vaginal vault after hysterectomy) with a symptomatic rectocele (618.5) and cystocele (618.5), a bilateral para-vaginal defect, and a small (less than 1 cm) benign vaginal wall nodule (221.1, Benign neoplasm of other female genital organs; vagina).

The operation that she underwent was an abdominal sacrocolpopexy (57280, Colpopexy, abdominal approach) with a rectus fascia graft (20926, Tissue grafts, other [e.g., paratenon, fat, dermis]), a Burch urethropexy (51840, Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple), a bilateral paravaginal repair (57284, Paravaginal defect repair [including repair of cystocele, stress urinary incontinence, and/or incomplete vaginal prolapse]), a posterior colpor-rhaphy (57250, Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy) and rectocele repair (included in 57250), a cystocele repair (57240, Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele), excision of vaginal wall nodule (57135, Excision of vaginal cyst or tumor), and cystoscopy (52000, Cystourethroscopy [separate procedure]).

You should bill 57280 first because it has the highest relative value unit. Next report 57284 appended with modifier -51 (Multiple procedures), which includes a unilateral or bilateral paravaginal repair, the Burch procedure and the cystocele repair. List 57250-51, which includes the excision of a vaginal tumor. For the cystoscopy, use 52000-51 unless this was performed only to ensure the sutures did not enter the bladder, in which case it would be a part of the operation and not billable separately. For example, if the urologist or gynecologist performed the cystoscopy to evaluate a previously known bladder tumor, 52000 is billable. Also report 20926, which is modifier -51 exempt. The claim form should read: 57280 57284-51 57250-51 52000-51 (if allowable) 20926.   Link 618.0 (Prolapse of vaginal walls without mention of uterine prolapse) and 625.6 to all procedures, with 618.0 as primary.

To arrive at the correct billing set, code every procedure as listed above, recommends Sandy Page, CPC, CCS-P, co-owner, Medical Practice Support Services, Denver. Then, look at CPT guidelines. For Medicare, also check the Correct Coding Initiative. If procedures are bundled, see if a separate reason exists for performing them; if so, unbundle with modifier -59 (Distinct procedural service) if allowable.

What is contained in the operative report determines the coding. Therefore, it's essential the report is written clearly, Page says. For example, in the [...]