Urology Coding Alert

Plus, see how to code for urinary diversion complications and use modifier 22 correctly.

You won’t find any shortage of urology coding advice on the internet, but you must be wary of sources that might fall short of what’s known as “authoritative” guidance. Coding guidance taken from forums and blogs, for instance, should be taken with a grain of salt if the nature of the instruction can’t be traced back to a few key sources.

Some of these sources include your code books, specialty societies, and the Centers for Medicare & Medicaid Services (CMS) policy manuals. Today, you’re going to highlight some key sets of instruction on the coding of balloon device placement procedures, urinary diversion complication diagnoses, and more from AMA CPT^® Assistant and AHA Coding Clinic^®. These monthly and quarterly bulletin newsletters include multi-specialty guidance on procedural and diagnosis coding, respectively.

“I utilize CPT^® Assistant and Coding Clinic^® as helpful resources that offer insights into CPT^® and diagnosis coding through clinical scenarios, Q&As, and more,” says Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania.

Take your urology coding to the next level by homing in on the following key sets of guidelines.

Discern Between 0548T-0551T

The first set of guidance to consider comes from a recent CPT^® Assistant article (Volume 30, Issue 8). At the heart of the discussion are four Category III codes (0548T- 0551T) that were new to the CPT^® code set in 2020. This set of procedures involves the placement, removal, and addition of fluid to one or two “laterally placed saline balloons that are fully adjustable for long term use.”

To consider: “Category III ‘T’ codes are created for emerging technology and act as tracking codes to help determine how often a particular service or procedure may be utilized in the future,” explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook. It’s important to keep in mind that reimbursement for these services varies among payers. Hence, there are no relative value units (RVUs) or Medicare Physician Fee Schedules (MPFSs) associated with these codes.

“When applicable, you should bill for a Category III code in place of an existing Category I code so long as the code description aligns with the surgeon’s work. Category III codes will remain in their respective section of the CPT^® code book for up to five years before either being removed or converted to a Category I code,” adds Ferragamo.

At first glance, it might be hard to distinguish between each respective procedure. When working on an operative report involving one of these services, you should utilize the following notes to determine which of the four codes to report:

• 0548T (Transperineal periurethral balloon continence device; bilateral placement, including cystoscopy and fluoroscopy) – This procedure involves two incisions on either side of the midline of the perineum. Beginning with the first incision, the surgeon will remove and push wires unilaterally from the first balloon device. A port for the balloon device is then placed in a subcutaneous pocket under the perineal skin. The surgeon will repeat the procedure on the contralateral side.
• 0549T (… unilateral placement, including cystoscopy and fluoroscopy) – Similar to 0548T, 0549T involves a one-sided perineal incision with subsequent placement of the balloon device. You want to look out for documentation for insertion of a single port following confirmation of the placement and positioning of the balloon device.
• 0550T (Transperineal periurethral balloon continence device; removal, each balloon) – This procedure involves the removal of any permanent adjustable balloon continence devices. Typically, these services are performed on patients who experience complications following the placement of the balloon device, such as leakage. The operative report will include documentation of an incision to access the port, fine needle aspiration (FNA) of residual fluids, and subsequent removal of the balloon device.
• 0551T (Transperineal periurethral balloon continence device; adjustment of balloon(s) fluid volume) – Report code 0551T for surgeries that treat balloon leakage without removing one or both devices. Instead of performing a typical removal, CPT^® Assistant explains that the surgeon will add fluids to the balloon(s) in order to “increase urethral resistance and decrease urinary leakage.” An operative note for 0551T will include a needle puncture into the titanium port. The surgeon adds .5 to 1 cc of saline to the balloon. When performed bilaterally, the surgeon repeats the procedure on the contralateral side.

Coder’s note: For removal of bilateral balloon devices, you should not append modifiers RT (Right side), LT (Left side), or 50 (Bilateral procedure) to code 0550T. Instead, you will report 0550T as two units since code 0550T has a medically unlikely edit (MUE) of 2. Keep in mind that some payers may require an overriding modifier, such as modifier 59 (Distinct procedural service), on one of the two reported codes.

Check Fine Print for Urinary Diversion Complication Diagnoses

Shifting toward some recent urological diagnostic coding guidance, have a look at an important Q&A in Q3 of the 2020 AHA Coding Clinic^®. Here, you’ll encounter a question involving a patient with acute pyelonephritis secondary to an ileal conduit, or neobladder, urinary diversion. Before diving into coding considerations, you first want to identify some key terms.

Refresher: An ileal conduit, also known as a neobladder, is performed for patients in need of a urinary diversion when the bladder has been removed or is not functioning properly. This may either be the result of trauma or an underlying pathology. In the case of an ileal diversion, the surgeon will create an ileal conduit by taking a segment of the ileum, anastomosing the ureters, and forming a cutaneous or skin stoma for drainage. This allows urine to drain into an external device/pouch outside of the body.

Coding Clinic^® instructs that since the pyelonephritis is the result of (secondary to) the ileal conduit, your primary diagnosis will be a complication code involving the ileal conduit. While you don’t technically have any direct information alluding to the complication of the ileal conduit, you should deduce from the secondary pyelonephritis that the complication involves an infection or inflammatory reaction secondary to the ileal conduit.

Based on this rationale, Coding Clinic^® instructs that you should report T83.598A (Infection and inflammatory reaction due to other prosthetic device, implant and graft in urinary system, initial encounter) as the principal diagnosis. Coding Clinic^® adds that you may also “assign code N10 (Acute pyelonephritis), along with a code for the infectious agent, if known.”

Gain Additional Insights Into Modifier 22 Reporting

Your last point of order comes by way of CPT^® Assistant (Volume 30, Issue 5). This issue includes some helpful guidance on modifier 22 (Increased procedural services) reporting as it pertains to the amount of time a procedure takes. Within Appendix A of the CPT^® code book, CPT^® outlines a few of the following variables to consider when making a modifier 22 determination:

• Increased intensity of the surgery;
• Increased time to do the surgery;
• Technical difficulty of procedure;
• Severity of patient’s condition; and
• Physical and mental effort required.

CPT^® Assistant argues that time, while not the sole indicator of modifier 22 usage, “can be used as a measure” of increased physician work. However, CPT^® Assistant goes on to explain that documentation from your physician or other qualified healthcare professional “should reflect all elements of the increased work” to support use of modifier 22.

While some of this guidance is open to interpretation, the general idea is that you should include all elements of the report in your justification for modifier 22 — even if the time variable alone meets the criteria.