Urology Coding Alert

Version 8.0 of the Correct Coding Initiative (CCI) contains several changes for urology. The most controversial involves new code 52001 (Cystourethroscopy with irrigation and evacuation of clots), which includes 52000 (Cystourethroscopy [separate procedure]) and 51700 (Bladder irrigation, simple, lavage and/or instillation).
Unbundling  
Unbundling of 52001 with 52000 or 51700 is allowed under certain circumstances. For example, a urologist performs cystoscopy and irrigation of blood clots in the morning. Report 52001. Later that day, the urologist irrigates the bladder again. Bill 51700-59 (Distinct procedural service), indicating that the second irrigation was performed on the same day but at a different encounter than the first.
Fee Schedule  
New code 52001 pays more than 52000 when performed in a hospital, but much less than 52000 when performed in the office because Medicare has not yet given 52001 a place-of-service differential. The relatively low fee for 52001 done in the office has prompted urologists to propose coding for in-office clot evacuation as though 52001 is nonexistent. They feel it is fair to bill 52000 and 51700 in the office (these codes are not bundled).
The Urologists Viewpoint  
Code 52001 (nonfacility and facility relative value units [RVUs] 3.67) will probably be performed in a hospital or ambulatory surgical center, says Michael A. Ferragamo, MD, professor of urology at the State University of New York, Stony Brook. A large-diameter cystoscopy sheath is typically inserted into the bladder, and clots are evacuated through this sheath using an Ellik or piston syringe evacuator. After irrigation, the cystoscopic telescope is placed through the same sheath, and a cystoscopic viewing of the bladder is accomplished. For the above work, report 52001 on one line for the urological work performed. In a facility setting, 52001 pays much more than 52000 (3.67 compared to 2.82 RVUs).
 
In contrast, Ferragamo says, in the modern urology office, cystoscopy is performed with a small-diameter flexible cystoscope. Because of its small size the irrigation portal is inadequate for evaluation of blood clots. On the rare occasion when it becomes necessary to irrigate clots from the bladder in an office setting, a large-diameter catheter is inserted for irrigation, and after its removal cystoscopy is performed with the introduction of the flexible scope. For the above in an office setting, bill 52000 (nonfacility RVUs 5.58), rather than 52001 (facility and nonfacility RVUs 3.67). If irrigation prior to cystoscopy is significant, report 52000 and 51700-51 (Multiple procedures) to delineate the separate endoscopic manipulations performed.
 
One must understand the differences noted when performing and coding these procedures, Ferragamo says. For example, if a urologist performs a cystoscopy (52000) and a urethral [...]