Question CPT 52000

maryir

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Can a physician charge for a cystoscopy (CPT 52000) when a RN performs the procedure with the physician in attendance?
 

thomas7331

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Theoretically, yes, if the procedure is within the scope of practice of the RN's license and all of the 'incident to' requirements have been met. However, I seriously doubt that is the case - are you sure this is what the RN performed? I have never heard of this procedure performed by an RN. This is a diagnostic procedure and an RN is not qualified to make a medical diagnosis. The RN may assist and perform parts of the procedure, if they are properly licensed and trained, but only a physician can perform the diagnostic portion.
 

maryir

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Theoretically, yes, if the procedure is within the scope of practice of the RN's license and all of the 'incident to' requirements have been met. However, I seriously doubt that is the case - are you sure this is what the RN performed? I have never heard of this procedure performed by an RN. This is a diagnostic procedure and an RN is not qualified to make a medical diagnosis. The RN may assist and perform parts of the procedure, if they are properly licensed and trained, but only a physician can perform the diagnostic portion.
Hi and thank you for responding.
I will copy the RN note tomorrow to show why I have concerns and you can let me know if I'm on the right track. Thanks again.
 

maryir

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Here's the RN note - but after further review, I believe the RN is performing the prep while the Dr might be performing the Cysto (only says Dr present for procedure). The Dr has a separate note but it's only documenting the results of the procedure. Can the two together be sufficient documentation to charge or is the documentation required to be under one note, signed and attested by the physician?

Patient here for cystoscopy.
Procedure instructions were reviewed with patient and verbalized understanding.
Pt signed the consent.
Allergies and medications were reviewed.
500 mg of Keflex was given as prophylaxis, pt was supine on the exam table and prepped in standard sterile fashion.
Betadine prep prior to lidocaine 11 mL glydo into the urethra, penile clamp applied.
0.9% NaCl used for irrigation fluid.
Dr. and Dr. present for the procedure using a flexible scope #2229810 processed in Sterrad cycle #8666.
Pt tolerated procedure well, AVS was provided.
 

thomas7331

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Here's the RN note - but after further review, I believe the RN is performing the prep while the Dr might be performing the Cysto (only says Dr present for procedure). The Dr has a separate note but it's only documenting the results of the procedure. Can the two together be sufficient documentation to charge or is the documentation required to be under one note, signed and attested by the physician?

Patient here for cystoscopy.
Procedure instructions were reviewed with patient and verbalized understanding.
Pt signed the consent.
Allergies and medications were reviewed.
500 mg of Keflex was given as prophylaxis, pt was supine on the exam table and prepped in standard sterile fashion.
Betadine prep prior to lidocaine 11 mL glydo into the urethra, penile clamp applied.
0.9% NaCl used for irrigation fluid.
Dr. and Dr. present for the procedure using a flexible scope #2229810 processed in Sterrad cycle #8666.
Pt tolerated procedure well, AVS was provided.
I think you are correct that the RN is just performing the prep. The note you have copied here is just a nursing note - there is no documentation here about what procedure was actually done and no way to assign a CPT code based on this. You do need to code from the physician's note, which needs to state what was performed, not just the results. If the physician's documentation is not clear as to what procedure was done, then I would query them.
 

maryir

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Below is the complete physician procedure note - I didn't think it was sufficient because of lack of documented details of what was performed. Drs will push back because of RN documentation. Need to make sure I'm not be too picky.

Operation: Cystoscopy
Anesthesia: None
Imaging:
Urethra: normal in appearance
Prostate: not applicable
Bladder: Large mass-effect from the left side of her bladder distorting the bladder and trigone which was edematous. There is a large mass with a fungating apex that can be seen and pictures were taken. The right side of her bladder and the posterior portion of the bladder were unremarkable
Ureteral orifices: Clear efflux was seen from both ureteral orifices, and however the trigone and orifices themselves were edematous
Finding of note: As above
Additional Procedure: Not applicable
 

fwnewbie

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My question is why didn't you post the nursing note and doctor note at the same time, like when you asked the question? No RN I've ever known could/would do a cystoscopy. The doctor's note is minimal and doesn't describe what s/he is doing but it does list what was seen at each step. Just my opinion.
 

thomas7331

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It may seem self-evident if the doctor is saying a cystoscopy was performed, but you could point out that neither the RN nor the MD have even documented inserting the scope, which is the first step of the procedure itself.

They really should know better than this. If it's a one-time thing, I would probably let it go, but doctors need to document in detail what they did, not just what they saw. If the insurance companies audited this, they could make life difficult and cost the practice money, so if you put it that way and not treat it like you're being picky, then maybe they'll understand. They don't need to write a novel - just a simple description of what was done is sufficient.
 

maryir

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You're correct, I should have posted them together. So, in your opinion, is the minimal documentation enough to charge or does the Dr have to add the detail of the procedure performed?

As an FYI - I took over the Cysto coding since COVID and noticed the documentation (my perception) shortfall. The notes were processed without review prior and the Drs are use to how they've submitted documentation. I talked with management but haven't received direction. This forum was my only resource as I'm usually told I'm too rigid about what documentation guidelines to maintain.

Thank you for your help. It's much appreciated.
 

twizzle

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You're correct, I should have posted them together. So, in your opinion, is the minimal documentation enough to charge or does the Dr have to add the detail of the procedure performed?

As an FYI - I took over the Cysto coding since COVID and noticed the documentation (my perception) shortfall. The notes were processed without review prior and the Drs are use to how they've submitted documentation. I talked with management but haven't received direction. This forum was my only resource as I'm usually told I'm too rigid about what documentation guidelines to maintain.

Thank you for your help. It's much appreciated.
You are right to be rigid in what is acceptable documentation and what is not. In my opinion this note contains insufficient documentation to bill 52000 and, as Thomas said, the payer could make life very difficult for the provider if an audit was done. You are also right to reach out to management about your concerns and they (management) have a duty to you and the provider to give direction. Every entity should have a compliance program in place that is regularly updated and this would be a perfect example of a non-compliant operative report.

If the doctors have always documented this way then now would be a good time for someone (management/compliance) to tell them that 'this way' is not acceptable; it will save a lot of headaches down the line. No great extra information is needed on the reports other than the indications for the procedure (why was it done? The findings are within the note but medical necessity for performing the procedure is not documented) and the actual insertion of the scope. Of note, the report says 'her bladder' yet penile clamp applied' (to what?) is documented which is a tad confusing.
 

fwnewbie

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You're correct, I should have posted them together. So, in your opinion, is the minimal documentation enough to charge or does the Dr have to add the detail of the procedure performed?

As an FYI - I took over the Cysto coding since COVID and noticed the documentation (my perception) shortfall. The notes were processed without review prior and the Drs are use to how they've submitted documentation. I talked with management but haven't received direction. This forum was my only resource as I'm usually told I'm too rigid about what documentation guidelines to maintain.

Thank you for your help. It's much appreciated.
You are in a sticky spot for sure, but stand up for what you've been taught is right and see that the docs play fair! lol
 

maryir

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Hi - I finally received a response from my management but sort of a double edge answer.
They affirmed that additional information is needed but they also wanted me to confirm the specific documentation required.
Now, I don't want to confirm/validate what specific documentation is required without backup references. Does anyone have a reference which would support that statement? I don't have access to specialty associations and I've Googled everything I can think of without success. You are my last source. HELP please! What am I doing wrong?
 

SharonCollachi

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The Medical Affairs Office of UCSF (University of California San Francisco), has a standardized procedure for cystoscopy that goes through each step, which is what needs to be documented. That document is here.

The Journal of Clinical Urology has this: Improving the documentation of flexible cystoscopy notes: Article (PDF Available)inJournal of Clinical Urology 11(6):205141581876152 · March 2018 DOI: 10.1177/2051415818761527
 
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