Question Retrograde Pyelogram

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Calhoun, Georgia
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Good Morning I'm looking for some help with coding denials for Retrograde Pyelogram-CPT 74420(26) and Cystourethroscopy-52332. As I have reviewed there are no active CCI edits between the two codes, however Aetna and BCBS are continuously denying to reimburse for the retrogrades...Can anyone help explain if their practices run into this issue and or what is the warranted supporting information in billing both? Thank you.
 

thomas7331

True Blue
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3,258
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CCI is part of the CMS reimbursement methodology, and although many payers do follow it, there is no requirement that they do so, and some commercial plans do in fact use their own bundling logic. If your practice is contracted with these plans, then most likely there is a clause in your contract that states that you will accept and abide by their policies, in which case there isn't much you can do to overturn these denials.

If this is the case with your denials, one strategy I can recommend is that you quantify the volumes and dollar amounts that you are having to write off due to the payers' policies, and that when your contract comes up for renewal you use this information to negotiate for a rate increase. The rationale for bundling is that the compensation for the bundled code is already included in the rate paid for the more extensive procedure. If they are not reimbursing you separately for the interpretation of the pyelogram, then you would expect that the rate they pay you for the procedure itself should reflect an increased amount over other payers to offset this.
 

catharine

Networker
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47
Location
Sanger, CA
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If you are only doing a cystoscopy and a retrograde pyelogram you should be using 52005, while this can be a bilateral code, insurances only acknowledge this as unilateral since we only have one bladder. This may be your issue. However since 52005 and 52332 are bundled (I'm assuming your physician placed a stent and this was not a type-o) you should be able to bill the 52332, 74420-26. As long as your Dr. dictated the pyelography, you should be able to appeal. If they did not I would only bill for the 52332 or if no stent was placed 52005.
 

Jessim929

Guru
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If you are only doing a cystoscopy and a retrograde pyelogram you should be using 52005, while this can be a bilateral code, insurances only acknowledge this as unilateral since we only have one bladder. This may be your issue. However since 52005 and 52332 are bundled (I'm assuming your physician placed a stent and this was not a type-o) you should be able to bill the 52332, 74420-26. As long as your Dr. dictated the pyelography, you should be able to appeal. If they did not I would only bill for the 52332 or if no stent was placed 52005.
The only caveat with the 74420-26 is if Radiology also reviews the film and dictates and billed.
 
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