Urology Coding Alert

Urologists frequently wonder if they can bill for an endoscopic and surgical procedure at the same surgical session. If you start a procedure endoscopically but it fails and you need to do it as an open procedure, you can bill for the open procedure only. But if the endoscopic procedure is done diagnostically, and you consequently decide to do an open procedure, you can bill for both with the proper modifier.

You can bill for both procedures, says Michael Ferragamo, MD, a coding expert who practices with Ferragamo, Bruno, Efros, a three-urologist practice in Garden City, N.Y. But youll need to explain what you did, and youll need to use a modifier.

Diagnostic vs. Exploration

The key to getting paid for both procedures lies in the difference between the endoscopic procedure that failed and the endoscopic procedure that was diagnostic. When an endoscopy is a diagnostic service, and a decision for surgery is made based on it, then you can bill separately, says Cynthia Jackson, RRA, CPC, coding specialist for Emory Clinic Urology Group, a five-provider practice in Atlanta. But you need to use modifier -59 (distinct procedural service) to show that the diagnostic endoscopy is different from the surgical treatment, she adds. For example, if you tried to perform a diagnostic ureteroscopy, and then you ended up doing an open procedure, you would bill 52335-59 and the appropriate code from the open series (50610-50630).

Jackson stresses that surgeons cannot be paid for exploring the surgical field. What is the difference between a diagnostic endoscopy and exploration? If they know when they go in there what is there, then its exploring the surgical field, says Jackson. If they dont know or if they find something different from what they thought was there so they need to convert to an open procedure, then its diagnostic.

You may perform an endoscopy to determine whether you can perform the procedure endoscopically. In this case, you can get paid for both, says Ferragamo, because the endoscopic procedure is a procedure to help you determine the approach.

Unsuccessful Ureteroscopy

For example, a patient has a calculus (592.1) that you worked on for two hours using the ureteroscope. It just wont come out, and you have to write a note in the report saying that you decided to convert the procedure to an open procedure so that it could be billed. You do a ureterolithotomy [an open procedure], and thats the only code you can use, not the ureteroscopy, says Ferragamo. So you would bill 50610 (ureterolithotomy; upper one-third of ureter), 50620 (middle one-third of ureter), or 50630 (lower one-third of ureter), depending on where the stone was. But you should append a modifier -22 (unusual procedural services) to show that you did a lot more than the ureterolithotomy, says Ferragamo.

Unsure Ureteroscopy

What if you perform a ureteroscopy but you arent sure what you will find and you find something that indicates that you need to operate using an open procedure? For example, you may find a stricture that needs to be resected (593.3). Maybe you know theres retention, and youve done a cystourethroscopy, but you dont know whats farther up, says Jackson. You go up with the ureteroscope for the first time, and you see the patient has a stricture that needs to be resected. This would require an open procedure. In this case, you can bill for both procedures. Use codes 52335 (cystourethroscopy, with ureteroscopy and/or pyeloscopy [includes dilation of the ureter and/or pyeloureteral junction by any method]) and 50700 (ureteroplasty, plastic operation on ureter [e.g., stricture]), says Jackson.

You do not need to use modifier -59 on the 50700 when billed with 52335 because these services are not bundled and neither one has a separate procedure indicator, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding and reimbursement consulting firm based in Denver. But you would use different diagnoses stricture (593.3) for the ureteroplasty, and retention (788.20) for the cystourethroscopy.

Prostatectomy That Turns into an Open Procedure

Another example of an endoscopic procedure that could turn into an open procedure is a prostatectomy. You dont know if it will be open or transurethral when you start, says Ferragamo. So you do a cystourethroscopy and find out. Perhaps you find out that the prostate is too big for a transurethral resection of prostate (TURP), so you have to perform an open procedure. Then you can bill for the open procedure and the cystourethroscopy. If you did a suprapubic prostatectomy, you would bill 55821 (prostatectomy [including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy]; suprapubic, subtotal, one or two stages) and 52000 (cystourethroscopy [separate procedure]).

If the urologist needs to get around a stricture before visualizing the prostate, report 52281 (cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female), says Page. Medicare bundles 52281 into 55821, however, so modifier -59 would need to be appended to the 52281, she adds.

You would also have to use a modifier because this is a multiple procedure. Not all coders use modifier -51 (multiple procedures), as Medicare puts it in automatically, but Ferragamo recommends it. Based on pure CPT guidelines, the modifier -51 is correct for the prostatectomy scenario, says Page. However, most payers have built in an edit, if for no other reason than to reduce the number of claims that pay at 100 percent of the allowable when multiple procedures are reported.

Modifiers -52 and -53

Another option to gain reimbursement when an endoscopic procedure becomes an open procedure is to use modifier -52 (reduced services) or -53 (discontinued procedure), says Ferragamo. This comes from a recent American Urological Association (AUA) recommendation on how to bill for a failed laparoscopic nephrectomy (50546, 50547) that is converted to an open nephrectomy (50220). Lets say you begin the endoscopic procedure and decide on your own that it cant be done this way, he says. Then you would bill both the open, and the laparoscopic with the modifier -52 appended. But what if you begin the procedure laparoscopically and need to stop it in the interest of the patients well-being, for excess bleeding, for example? You would bill the open and the laparoscopic with the modifier -53. We were doing a laparoscopic adrenalectomy, and there was a lot of bleeding, so we had to switch to an open procedure, says Ferragamo. We did research and found that the correct way to bill was with a modifier -53 on the laparoscopic procedure. Modifier -53, says Ferragamo, is for when something goes wrong, and you have to stop the procedure.

Modifier -52 vs. Modifier -22

Which is better, modifier -52 or modifier -22, when you convert from an endoscopic to an open procedure but the reason is not because the endoscopic procedure failed? I like -52 better because it gives an idea of what you did, says Ferragamo. Modifier -52 indicates that the scope procedure is incomplete.

What is the difference between the -52 and -22 modifiers? Page explains. Its based on the code you want to report, she says. If you do only part of a procedure and there is no code for the part you completed, you bill the code for the complete procedure with modifier -52. For example, you attempt to dilate a stricture in the office but are unsuccessful. You would bill 53620 (dilation of urethral stricture by passage of filiform and follower, male; initial) with a -52 modifier appended. Conversely, explains Page, modifier -22 is used when there is no code to describe the services provided, and the services are over and above what is normally required to complete the procedure (such as the prostatectomy example given above). Another option, other than the -22 modifier, is always the miscellaneous code (for example, 53899 [unlisted procedure, urinary system]).

Note: When billing an unlisted procedure code, you must submit an op report and assign a fee based on another code with a comparable work value.

Documentation and Determining the Approach

What you write in your notes is very important, Jackson and Ferragamo agree. In the case of a prostatectomy, In your operative procedure notes, you should say that a cystourethroscopic procedure will be performed to determine the proper approach for the prostatectomy, says Ferragamo. If you decide then that you can do a TURP, you will not get paid for the cystourethroscopy because its bundled. This is an endoscopic rule the scope is there anyway, and you will not get paid for putting it in again. If you decide that you have to do an open procedure, then you get paid for both, but you have to explain this in your notes.

In the case of the ureteral stone, where the physician works for two hours to remove it via ureteroscope and ends up having to do an open procedure, you would have to document the amount of time you spent and the problems you encountered, says Ferragamo. Then, when you use the modifier -22, you will get 100 percent for the open procedure, and you should ask for at least 50 percent in addition. With modifier -22, the provider decides how much more the additional work is worth.

But Ferragamo has found that its better not to send in the operative report with the initial claim. Anytime you send something in with an op report, they take the HCFA 1500 and throw out the rest, he says. Its better to send in the claim with the modifier -22, and then let them ask you for the report. That way, you know who to send the report to, and it wont get lost. It seems as if it would take longer this way, but it doesnt, Ferragamo says.