Urology Coding Alert

You could be missing out on as much as 15 percent per procedure

If you don't know the rules for unbundling and modifying multiple cystoscopies your urologist performs on the same day on the same patient, you could be missing out on hundreds of dollars of deserved reimbursement.
 
By using modifiers correctly and adjusting, urologists can maximize their billing for these multiple claims. Confusion abounds about whether to use modifier -59 (Distinct procedural service), modifier -51 (Multiple procedures), both, or no modifier at all with multiple endoscopies. Be an Ace of Base Medicare has special rules for reimbursing multiple procedures when those procedures are endoscopies and include a diagnostic endoscopy or common base code. This is called the "multiple endoscopy rule."
 
In these cases, payment for a second endoscopy is based on the difference between its relative value and the base code's value, and so it goes for the third procedure. If an endoscopy is billed with another endoscopy in the same family (i.e., an endoscopy that has the same base procedure), payment for the second endoscopy is based on the difference between the fee paid for the procedure minus the fee for the base procedure.
 
If one does multiple bladder biopsies, 52204 (Cystourethroscopy, with biopsy), the first biopsy is paid in full and subsequent biopsies at full price minus the fee for the base procedure (52000, Cystourethroscopy [separate procedure]). Here are examples using the New York-area #2 fee schedule:
  52204               $146.68
  52204-59          $23.20
  52204-59          $23.20
 
The fee for the subsequent biopsies is calculated by: $146.68 (52204) - $123.48 (base fee for the cystoscopy, 52000) = $23.20.  
The Medicare fee scale (assuming the procedure is nonfacility) would be:
  52204               $126.91
  52204-59          $19.87
  52204-59          $19.87
 
The fee for the subsequent biopsies is calculated by $126.91 (52204) - $107.04 (base fee for the cystoscopy, 52000) = $19.87.

Modifier -59 is appropriate here because it refers to bladder biopsies from different locations within the bladder and not double or triple billings. For commercial carriers, you may need to append modifier -51. However, for Medicare do not add modifier -51 - Medicare will append the modifier to the proper CPT codes when necessary.
 
Terry Vennell, CPC, billing manager for Knight, Boline & D'Amico in Harrisburg, Pa., explains. "If it's Medicare, you can bill both, and then Medicare will subtract the cost of the endoscopy from the second procedure."
 
Linda S. Dietz, RHIA, CCS, CCS-P, coding specialist of the National Correct Coding Initiative, warns that NCCI [...]