Urology Coding Alert

Question: I am receiving denials from my Medicare carrier when I report CPT 53899 (Unlisted procedure, urinary system) for Botox injections to the bladder. Am I choosing the incorrect code? How should I report these injections to be reimbursed?

Illinois Subscriber
 
Answer: Unfortunately, your code choice is not at fault for your denials - regardless of the code you use, it won't be easy to get reimbursed for your physician's Botox injections.
 
Even though many urologists use Botox injections to treat overactive bladder, most carriers are denying these claims as not medically necessary. To cover your bottom line, have the patient sign an advance beneficiary notice that informs him that he will be financially responsible for this treatment should his carrier deny the claim as not medically necessary.
 
For those carriers that will reimburse for Botox, you will most likely need to report one of two sets of codes. Some carriers require you to report 52000 (Cystourethroscopy [separate procedure]) for the cystoscopy and 51700-59 (Bladder irrigation, simple, lavage and/or instillation; Distinct procedural service) for the injections into the bladder. Other carriers require that you report 53899, as you suggested in your question, for the cystoscopy and injections into the bladder muscle.
 
Remember, you should report the HCPCS supply codes for Botox if your office supplies the Botox. In this case, report J0585 (Botulinum toxin type A, per unit) for the supply of the first 99 units of Botox and J0585-59 for an additional unit of the drug for a total of 100 units.    
 
Urologists typically administer 100 units of Botox in about 30 bladder injections at 0.3 ccs per injection. Because in the insurance 1500 form the 24G, days or units, column will only accept two numbers, the above coding will be necessary when 100 or more units of Botox are used.
 
Be sure to include a detailed report of the number of injections and the amount of Botox the physician administered in the operative report. And if your carrier does cover Botox injections, be sure you are reporting ICD-9 codes that indicate that the procedure was medically necessary. One such code may be hypertonicity of bladder (596.51).
 
- Answers to You Be the Coder and Reader Questions contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 19-urologist practice in Indianapolis.