Urology Coding Alert

When it is clinically appropriate to perform a procedure, but there is no way to obtain proper payment for it, you need to make sure you get the patient to sign a waiver in case the payer will not reimburse.

For example, a patient with bladder cancer has a total cystectomy (51570, cystectomy, complete; [separate procedure]). The diagnosis code for the cystectomy would be 188.9 (malignant neoplasm of the bladder). The tricky part is when the urologist removes the prostate as well, because often, although not always, the bladder cancer involves the prostate. The urologist may not be able to find any pathology to support a prostate cancer diagnosis, but has reason to believe that the bladder malignancy has invaded, or is likely to invade, the prostate. Consequently, the prostate is removed.

In addition to billing for the cystectomy, the urologist wants to bill for the radical prostatectomy 55810 (prostatectomy, perineal radical;), 55812 (prostatectomy, with lymph node biopsy[s] [limited pelvic lymphadenectomy]), or 55815 (prostatectomy, perineal radical; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes). The combination of codes billed will depend on the procedures performed and any bundling edits specific to the payer (e.g., CCI).

The prostatectomy code is appended with a modifier
-51 (multiple procedures). But what diagnosis code can be used on that code? The only option I can see is the bladder cancer diagnosis, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding, reimbursement, and compliance consulting firm based in Denver, Colo. It would be inappropriate to code a prostate diagnosis without pathology. Medicare, however, does not always pay for a prostatectomy without a prostate cancer diagnosis. So coding the prostatectomy with the bladder cancer may not always be reimbursable.

Many physicians have not been charging for both a prostatectomy and a radical cystectomy because they assume that a prostatectomy is included in a cystectomy. It is not. And by not charging for the prostatectomy, they are losing money.

But, physicians are willing to charge for both if Medicare will pay for both. If Medicare will not, they are reluctant to bill their patients for it. Since many physicians have not been billing for the prostatectomy anyway, they might not mind writing off the procedure if Medicare will not pay for it. Nevertheless, have the patient sign an advance beneficiary notice (ABN) accepting financial responsibility for all insurance claims on this procedure, says Page.