Urology Coding Alert

Per the CCI edits, urologists cannot bill CPT 52005 (cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) with any transurethral removal of bladder tumors (TURBT) 52224 (cystourethroscopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesion[s] with or without biopsy), 52234 (cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 to 2.0 cm]), 52235 (... MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) and 52240 (... LARGE bladder tumor[s]).

Medicare assumes that the retrograde pyelogram (52005) is done to study the upper urinary tract as part of the TURBT, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Stonybrook.

However, if you perform the retrograde pyelogram for a reason other than the TURBT, you can bill both, using modifier -59 (distinct procedural service) appended to the 52005. You must have different diagnosis codes for each procedure.

For the TURBT, use 188.x (malignant neoplasm of bladder). The diagnosis code for the pyelogram is determined by the reason for the procedure.

Examples of -59 Use

According to Ferragamo, one circumstance that justifies appending modifier -59 is if the urologist performs a bladder tumor removal and there is also a stone in the ureter. The physician performs a retrograde to evaluate the stone. For the retrograde pyelogram, use diagnosis code 592.1 (calculus of ureter).

Another example is a questionable tumor in the upper urinary tract that may require further visualization. You may see a lesion in the renal pelvis via IVP, Ferragamo says. You want to delineate the lesion. Use 189.1 (malignant neoplasm of kidney and other and unspecified urinary organs; renal pelvis) for the 52005.

Another example, from Morgan Haus, CPC, CCS-P, coding compliance specialist with Urology of Indiana (17 urologists), is a tumor very near the ureteral orifice. They will do a retrograde pyelogram to get a better view, he says. Use 189.2 (malignant neoplasm of kidney and other and unspecified urinary organs; ureter) for the retrograde pyelogram.

Haus also gives the example of a bladder tumor resection on one side of the bladder and a retrograde pyelogram on the other side. You may need to do the retrograde pyelogram on the other side because of renal insufficiency (585) or flank pain (788.0), he says.

Bill modifier -59 for all payers, and be prepared to send your operative notes. Typically, this will be a review situation, Haus says.

Avoid Overuse of Modifier -59

Overuse of modifier -59 on 52005 will cause problems, notes Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a Denver-based coding, compliance and reimbursement consultancy. Be careful to document the reason for doing the pyelogram, Page recommends. If Medicare asks for documentation and the documentation does not support modifier -59, the claim will be denied in the case of a prepayment review, or Medicare will ask for a refund in the case of a post-payment review.

Code 52005 is bundled into the TURBT codes because the retrograde pyelogram is generally performed with TURBT as part of the treatment of the bladder tumor. If Medicare sees that urologists always use modifier -59 to be paid for both and the documentation does not support the use of the modifier, this may be regarded as abuse, Page says.