Urology Coding Alert

Urology coders are accustomed to billing for bundled procedures, which require one code covering a specific combination of procedures. But sometimes the urologist performs only some of the procedures. When this happens, the coder may be able to submit a claim using more than one code for a session, explains Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. You need to be aware of the various available options so you can obtain maximum ethical reimbursement for your practice, says Callaway-Stradley.

Medicare, CPT and Private Payer Rules Differ

The difference is evident when looking at how Medicare, CPT and private payer rules affect coding for cystoscopy with manipulation. Many urology coders were surprised to read in the September 2000 issue of CPT Assistant that they can use codes 52005 (cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) and 52330 (cystourethroscopy [including ureteral catheterization]; with manipulation, without removal of ureteral calculus) together.

Medicare guidelines do not allow billing of 52330 with 52005 52005 is the base endoscopy code for 52330. But CPT does not recognize Medicares special endoscopy rules, and neither do some private payers. Payers that do not recognize the special endoscopy rules may allow you to bill for both 52330 and 52005, as described in CPT Assistant.

There is additional confusion when the coder has to consider also billing for a stent placement since Medicare has that code bundled into 52330, according to the CCI edits. Stone manipulation is rarely done without a stent, and the code for a stent 52332 (cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) includes 52330 under the CCI.

Finally, remember that when a stent is left behind at the end of a procedure, it is billable by using modifier -51 (multiple procedures) under CPT.

Understand Medicare Rules

The following scenario is for a Medicare patient, as explained by Michael A. Ferragamo Jr., MD, FACS, clinical assistant professor of urology at State University of New York Medical College, in Valhalla, N.Y.

Step 1: Using 52005 and 74420 with -26. A patient has a calculus lodged in the ureter, which is discovered by cystourethroscopy (52005) in combination with urography, (74420, urography, retrograde, with or without KUB). If the radiological procedure is done in the hospital but the urologist interprets the x-ray, the urologist should append modifier -26 (professional component) to the 74420. Often, says Ferragamo, the pyelogram is done in the hospital, and the urologist reads the film.

Step 2: Using 50590 and 52330. Then, the urologist moves the stone back up into the kidney to afford the patient some relief. You push the stone up into the renal pelvis, and you plan to do an ESWL [extracorporeal shock wave lithotripsy] later, says Ferragamo. Use code 50590 (lithotripsy, extracorporeal shock wave) for the ESWL procedure which is done to break down the stone when it is in the kidney. To bill for manipulating the stone back into the kidney and not removing the stone, use 52330.

Step 3: Using 52332 and 52330 with -59. After manipulating the stone back, the urologist usually inserts a stent that will remain in the body after surgery to hold the stone in the kidney, the urologist explains. According to Medicare, if you place an indwelling stent as described in this scenario, you cannot bill for the 52005, but can bill for the 52332 and 52330 by using -59 (distinct procedural service), notes Callaway-Stradley.

Commercial Payers and Additional Medicare Rules

For commercial carriers that do not recognize Medicares bundling rules, you should be able to bill for all three procedures in the previous scenario, appending modifier -51 (multiple procedures) to the two lesser valued procedures.

If treating a Medicare patient, you can bill 52330 and 52332 but not 52005 with either. For example, if the urologist tried to remove or manipulate a stone that was in the ureter, failed, and then placed the stent until performing another procedure at a later date, he or she could bill 52332 with modifier -59 and 52330. You can bill for both whether the patient is a commercial or Medicare patient. Both services are billable to Medicare and commercial carriers as long as the stent is left in place at the end of the procedure, rather than being used solely to aid the performance of the manipulation and then removed at the end of the procedure. If the patient is a commercial patient, you may also bill for 52005.

Tip: Commercial payers vary widely in the acceptable coding mechanisms for certain scenarios, and those listed are offered as a suggested format only. The payers you deal with in your practice may have very different coding requirements. When determining correct bundling policies, contact specific companies in advance to verify their policy.