Anesthesia Coding Alert

Cystoscopy the inspection of the interior of the bladder by means of a cystoscope is a common diagnostic procedure for conditions ranging from urinary tract infections and stress incontinence to follow-up of bladder cancer treatment. Although administering anesthesia during cystoscopy (or cystourethroscopy) is common, coding is not simple. By understanding the different pieces of the cystoscopy coding puzzle, you can ensure appropriate billing.

Know All the Options

Unlike some procedures that only have one or two applicable CPT Codes, more than two dozen codes apply to cystoscopy. They differ based on whether they report cystoscopy services alone or cystoscopy services offered at the same time as another procedure. The primary code for cystoscopy is CPT 52000 (Cystourethroscopy [separate procedure]). Other codes related to cystourethroscopy include the following:

 

52001-52010 for basic cystourethroscopy procedures

52204-52318 for cystoscopy with urethra or bladder procedures

52320-52355 for cystoscopy with ureter and pelvic procedures

52400-52601 for cystoscopy and associated prostate surgery.

Coding for cystoscopy is sometimes confusing," says Sharon Ryan, senior coder with the physician group Anesthesia Associates of Massachusetts in Westwood. "They're often performed with a number of other procedures, and it can be hard to know how to match everything up so it's coded correctly."

Of course, providing anesthesia for multiple procedures is usually rather straightforward the anesthesiologist simply codes for the highest base procedure and the total amount of time spent on everything. But because most procedures related to cystoscopies have the same base value three coders have to go a step further to determine which procedure to report.

"Your first choice when coding anesthesia is to use the procedure with the highest number of units," explains LaSeille Willard, CPC, lead biller with the physician group Anesthesia Consultants in Frederick, Md. "But when I'm coding for three or four procedures performed at the same session and they all have the same number of base units (as is often the case with cystoscopies), I go with the code that's most descriptive of all the services that were performed."

Willard cites these examples of procedures that are commonly performed with cystoscopy, and how she determines which code to report:

Cystouretheroscopy (sometimes referred to as a cysto-retrograde): Codes 52000 and 52005 are each three units, so Willard codes with 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) because it is a more in-depth code that includes cystourethroscopy as part of the procedure.

Cystoscopy with stent insertion or removal: Again, these are two procedures that are three base units each. So when they are performed together, she codes with 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) for stent placement. Stent removal along with cystoscopy is coded as 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple).

Cystoscopy with TURB: In this case, the TURB is a five-unit code (52500, Transurethral resection of bladder neck [separate procedure]), so it is billed instead of the three-unit 52000. The same holds true for cystoscopies performed with other five-unit (or higher) procedures such as TURP (52601, Transurethral electro-surgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) or lithotripsy (50590, Lithotripsy, extracorporeal shock wave). One rule of thumb to remember is that if stones or tissues (bladder or prostate) are removed, the unit value is usually five; diagnostic procedures, simple insertions or stent removals tend to be three units each.

As with other multiple-procedure situations, the anesthesiologist documents the appropriate codes for all procedures for which he or she provides anesthesia, but actually bills for only the procedure that has the highest base value or that describes the entire service more completely. Reporting all procedures helps document the services being provided by the physician or group for their records and provides carriers with complete records of what has been done. However, modifiers -51 (Multiple procedures) and -59 (Distinct procedural service) do not apply in these situations because the basic cystoscopy procedure is already included in most of the other procedures' more complete descriptors.

Because most procedures performed with cystoscopies are classified as Category A procedures by Medicare, they do not require a medically necessary diagnosis to justify anesthesia during the procedure.

Anesthesia or Surgical Codes?

Because some carriers require CPT Codes for anesthesia services that match the surgeon's codes, Willard says she virtually always reports cystoscopies and related procedures with surgical codes rather than anesthesia codes. She still uses the crosswalk to determine the number of units associated with the procedure and uses that number of base units plus time with the surgical code instead of the corresponding anesthesia code.

If your carrier requires CPT anesthesia or ASA codes instead of surgical codes, many of the same guidelines outlined above still apply. Coding can actually be easier because you do not have to match the surgeon's code exactly for the procedure.

If a cystoscopy is performed alone, it cross-references to anesthesia code 00910 (Anesthesia for transurethral procedures [including urethrocystoscopy]; not otherwise specified). Most other basic cystoscopy services also cross to code 00910, but other anesthesia codes that can apply include:

00912 ( transurethral resection of bladder tumor[s]) for a cystoscopy performed with fulguration and/or resection of a large bladder tumor or for transurethral resection of the bladder neck

00918 ( with fragmentation, manipulation and/or removal of ureteral calculus) for cystoscopies with removal of calculus, fragmentation of ureteral calculus, injection of implant material, or manipulation with or without removal of ureteral calculus

00860 (Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; not otherwise specified) for cystoscopies with treatment of ureteral stricture or with diagnostic ureteroscopy and/or pyeloscopy

00862 ( renal procedures, including upper 1/3 of ureter, or donor nephrectomy) for cystoscopies with treatment of intrarenal stricture

00872 (Anesthesia for lithotripsy, extracorporeal shock wave; with water bath) or 00873 ( without water bath) for cystoscopies with lithotripsy. Code 00873 would be used only when the operative report states that a water bath was used.

Selecting the Proper Code

When billing for cystoscopies with other procedures, Ryan and Willard agree that one of the biggest challenges is selecting the best fitting code.

"We usually only see cystoscopies used as an approach to something, such as a cystoscopy with a biopsy or fulguration of tumor," Ryan states. "The only thing we have to be aware of is making sure we pick the procedure with the highest base unit for coding."

Common sense can often help when determining the most appropriate code for a procedure. For example, 52000 is a diagnostic code that describes when the physician simply looks at the area and only takes about 10 minutes of surgical time. If the procedure time was more than an hour, a more extensive procedure was probably done; notations regarding bladder or prostate resections or waiting for x-ray studies help explain the procedure's length. Looking at the diagnosis code is another way to check that the procedure code is appropriate. A vague diagnosis such as pelvic pain might explain why a cystoscopy was performed with no additional procedure, but a diagnosis such as a prostate or bladder tumor probably merits additional procedures to help treat it.
 

"The doctors don't always document what was done, especially if for some reason the originally planned procedure isn't performed. The anesthesiologist could have been scheduled for one hour of time during a cysto-retro, but once the surgeon gets in he sees that the ureter is kinked and he needs to put in a stent. The surgeon may not explain the procedure any further, and the anesthesiologist isn't beside the surgeon to see exactly what was done. So the anesthesiologist documents the case as a cysto-retro, not knowing that it should be reported with the more descriptive code for stent placement. That's why it's a good idea to have the anesthesiologist ask the surgeon what he did, or for the coder to see operative reports whenever possible to ensure the cases are coded correctly," Willard adds.