Urology Coding Alert

Paying attention to what is included and excluded is key.

Many transurethral procedures are commonly performed to treat benign prostatic hyperplasia (BPH) in any urology practice or department. These procedures are more specifically used to treat urinary problems caused by an enlarged prostate or bladder and kidney stones, but coding these surgeries can be challenging. To make things easier, we’ve put together four scenarios to help you secure reimbursement for these commonplace procedures.

Read on to refresh your knowledge of transurethral coding.

Scenario #1: The provider performed Aquablation^® on a patient, which you documented with 0421T (Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed).The following day, the provider went back in and performed an evacuation of clots, and a resection of more prostate tissue through a resectoscope. How should this be coded?

Answer: In this case, following a transurethral waterjet ablation, report the initial transurethral resection of the prostate (TURP) with code 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)). The transurethral waterjet ablation is a procedure to treat benign prostatic hyperplasia like the TURP, but it is a different technology. As CPT^® 0421T is a Category III tracking code, there are no relative value units (RVUs) assigned and no specific global period. However, since the 0421T is carrier-priced, the carrier may assign a postoperative period. Since the Aquablation^® is the primary procedure with no global period identified, a modifier should not be necessary when the TURP is performed after an Aquablation^® procedure. According to Stephanie Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coding expert and consultant in Glen Burnie, Maryland, “It may still be beneficial to report the modifier 78 [Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period] with CPT^® code 52601.”

Scenario #2: The urologist performed a cystolitholapaxy for a stone greater than 2.5 cm. They also performed a channel TURP and a bilateral retrograde pyelogram. According to the medical documentation, a bladder stone was attached to the bladder mucosa in a circumferential fashion around the bladder neck. The urologist removed all visible stones and then performed a channel TURP to remove the mucosa that the bladder stone was attached to. They could see a stone growing through the wall of the bladder neck and prostatic base mucosa. They performed a superficial resection of the mucosa at the bladder neck and of the mucosa of the prostatic base to remove all the stone. How should you report this?

Answer: You should report 52500 (Transurethral resection of bladder neck (separate procedure)) because it appears that the resection was only at the bladder neck. You should also report 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple) for the removal of the stone. The coding procedure that carries the maximum RVU would be prioritized and reimbursed completely. The procedure with the minimum RVU, on the other hand, would follow in the sequence and its reimbursement would be adjusted downwards. This means that procedure with the lower RVU will be subject to the multiple procedure reduction.

Scenario #3: The pathologist received three pieces of prostate tissue in a single container. The operative report stated that the procedure was a TURP. Should this be billed as a partial prostate resection?

Answer: No. Despite the use of the term “resection” in both the operative report and the code definition, you should not report this case as a partial prostate resection pathology exam using 88307 (Level V - Surgical pathology, gross and microscopic examination … Prostate, except radical resection…).

Instead, you should bill the pathology exam of the specimen from the TURP procedure as 88305 (Level IV - Surgical pathology, gross and microscopic examination … Prostate, TUR …).

A note on units: During a TURP procedure, the surgeon typically resects the prostate with the resection cutting tool to excise bits of tissue and cauterize the excision site, resulting in multiple small tissue pieces being submitted to pathology. You should report just one unit of 88305 for the pathologist’s exam, even though there are multiple pieces.

Scenario #4: The urologist performed a TURP but because a vasectomy wasn’t performed at the time, the payer reduced the reimbursement. Does this seem correct?

Answer: No, this is not correct on behalf of the payer. The TURP CPT^® code 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)) was established at a time when certain procedures were routinely performed together. Therefore, these commonly associated procedures were incorporated into the TURP CPT^® code and listed in a parenthetical note, but performing a vasectomy during the majority of TURP procedures is no longer standard practice. This note is intended to clarify that these procedures, if performed concurrently, should not be billed separately.

The problem evidently arises from a misunderstanding of the code and its associated parenthetical note on behalf of the payer. “The note means that ultimately none of the procedures listed in the parenthetical need to be performed in addition to the initial procedure to bill 52601 without a modifier. This does, however, mean that if any of these procedures are performed at the time of a TURP, they should not be reported separately,” says Storck. There is no reason for the payer to reduce payment based on this scenario.