Urology Coding Alert

A Medicare change taking effect in July may add over $600 to your 50230 claims A bilateral nephrectomy may not be good news for the patient, but at least now there's good news for urology coders: CMS is providing a way to report that procedure accurately. A decision Medicare plans to implement in July changes the rules for reporting 12 urology procedures bilaterally.

The decision, described in CMS Change Request 3870, will update Medicare's Physician Fee Schedule on July 5, revising the "bilateral surgery indicator" for many CPT codes. This indicator, found in column T of the fee schedule's Relative Value File, determines the rules for reporting those procedures bilaterally, either by appending modifier -50 (Bilateral procedure) or by listing the code on two separate lines of the HCFA 1500 form and appending modifiers -LT (Left side) and -RT (Right side).

Starting July 5 - but retroactive to Jan. 1, 2005 - the bilateral surgery indicators will change from "0" to "1" for these procedures:
   50080 - Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm
   50081 - ... over 2 cm
   50120 - Pyelotomy; with exploration
   50125 - ... with drainage, pyelostomy
   50130 - ... with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy)
   50135 - ... complicated (e.g., secondary operation, congenital kidney abnormality)
   50200 - Renal biopsy; percutaneous, by trocar or needle
   50205 - ... by surgical exposure of kidney
   50220 - Nephrectomy, including partial ureterectomy, any open approach including rib resection
   50225 - ... complicated because of previous surgery on same kidney
   50230 - ... radical, with regional lymphadenectomy and/or vena caval thrombectomy. What this means: Modifier indicator "1" means that the 150 percent adjustment for bilateral procedures applies, says Jaime Cody, CPC, patient account representative for Urology of Virginia in Norfolk. If you code any of these procedures with the bilateral modifier or report them twice on the same day by any other means (for example, with -LT and -RT or with a "2" in the units field), Medicare carriers will base payment on the lower of the total actual charge for both sides, or 150 percent of the fee schedule amount for a single code.

The previous status of "0" attached to these codes prevented the 150 percent adjustment from being applied,  Cody says. Carriers based payments on the total fee schedule amount for one code, she says.

Example: The urologist performs a radical bilateral nephrectomy. You code 50230-50. Previously, you would have received reimbursement for just one code, calculated by multiplying the RVUs assigned to that code (32.18) by the conversion factor (37.8975), yielding $1,219.54 (unadjusted for geographic location).

Starting July 5, however, modifier -50 should trigger a 150 percent adjustment in the RVUs. 150 [...]