Urology Coding Alert

According to the Correct Coding Initiative (CCI), 52005 (cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) and 52332 (cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) are bundled procedures and not payable together. The rationale is that 52332 includes the catheterization. But many urologists bill for the 52005 also, using modifier -59 (distinct procedural service).

Medicare views the catheterization and pyelogram as an integral part of the stenting procedures, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Stonybrook, and a urology coding trainer. Under these circumstances, Medicare bundles these procedures and will only reimburse for the stent placement (52332), he says. Usually, the urologist needs a clear picture of the ureter before putting in the stent by doing the pyelogram.

But, CPT does not recognize the CCI bundling. In the January 2001 issue, CPT Assistant says, It would be appropriate to report 52332 in addition to 52005 when an indwelling stent is placed in addition to a diagnostic cystourethroscopy.

CPT Assistant stops short of recommending modifier -59. Instead, it states the following: It is important to note that the code edit includes a superscript of 1, which according to the CCI guidelines indicates that a modifier is allowed in order to differentiate the services provided. Therefore, according to the CCI Edits, provided the services described by codes 52332 and 52005 are performed, both codes may be reported with a modifier, as appropriate. You should refer to the CCI Manual for the list of modifiers that can be reported.

Although Medicare bundles the two codes, CPT gives strong support to coders who want to report them together when filing a claim with a private payer. For these private payers, a trial-and-error billing would seem in order, Ferragamo says. Bill 52332 and 52005-51 (multiple procedures), and ignore the CCI and follow the CPT guidelines. But he says not all private payers will pay for both procedures.

Medicare: Use Modifier -59 Only if Separate Ureter

For Medicare, bill 52005-59 with 52332 only if a different ureter is involved, Ferragamo says. If both procedures are performed at the same encounter but are not integral parts of each other, you can bill both, he says. For example, if there is a stone on one side where the stent needs to be placed, and a renal pelvic tumor on the opposite side needing a diagnostic retrograde pyelogram, code 52332 and 52005-59.

Morgan Hause, CCS, CCS-P, coding compliance specialist for Urology of Indiana, a 17-urologist practice in Indianapolis, agrees with the CCI bundling.

In my opinion, it is not appropriate to bill 52005, because you already have a catheter there, he says. But if it is the other ureter, you might be able to bill.

And indeed, it is difficult to see how billing 52005-59 fits the definition of modifier -59 if the ureter is the same for both. There is no separate lesion and no different site, unless 52332 is performed in one ureter, and 52005 in the other.

Different Encounters

If the procedures are performed during different encounters, that would also justify modifier -59 for Medicare, Ferragamo says. For example, the urologist performs the 52005, including the retrograde pyelogram, in the morning and discovers a renal pelvic stone and schedules the patient for an ESWL the next week. Later that afternoon, the patient has pain and fever when the stone unexpectedly drops into the ureter, causing an obstruction. That evening, the urologist performs a stent insertion to bypass the stone and relieve the pain. In this scenario, the date of service is the same, but it is clearly a separate and distinct encounter, and clearly for a separate and distinct purpose; therefore, you can bill the 52332 and the 52005 with modifier -59. The modifier is always attached to the lesser-paying, at-risk procedure.