Part B Insider (Multispecialty) Coding Alert

Want to know what you can bill with your transurethral resection of prostate claims?  Look no further

Urology coders, we hear you: Trans-urethral resections of the prostate (TURPs) give you a run for your money when it comes to coding. That's why we-ve compiled four of the most pressing TURP coding questions along with surefire answers from our experts. Read on to firm up your TURP coding knowledge.

Look to 52214 for Post-TURP Fulguration Inside the Global

Question: Our urologist performed a TURP procedure, and two days later he had to take the patient back to the operating room to perform a fulguration of bleeding vessels within the prostatic fossa. I am planning to report 52606. Is this accurate?

Answer: -Most urologists  usually use the transurethral approach when they fulgurate the prostatic fossa for bleeding after a TURP,-  says Laura Cwiklinski, office manager at Urology Partners, Inc. -It's a complication of the original procedure, and therefore, code 52214 (Cystourethroscopy, with fulgeration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands).-

Don't forget: Because the patient was still in his post-TURP global period append modifier 78 (Return to the operating room for a related procedure during the postoperative period) to 52214, says Debbie Price, RHIT, coder at Cullman Urology, PC.

For a TURP bleed, a surgeon may consider billing 52606 (Transurethral fulguration for postoperative bleeding occurring after the usual follow-up time), Cwiklinski says. However, the descriptor for 52606 states, occurring after the usual follow-up time. -I wouldn't consider two days to be usual follow-up time,- Cwiklinski says.

The facts: -You would report 52606 for fulguration of bleeding only after the 90 day global period has ended,- says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook.

In complicated cases when the urologist performs cystoscopy and finds multiple obstructing clots and initially irrigates them from the bladder and then fulgurates the bleeding, report the following combination, Ferragamo advises:

- 52001-59 (Cystourethroscopy with irrigation and evacuation of multiple obstructing clots; Distinct procedural service) for the cystoscopy and irrigation of the multiple and obstructing clots.

- 52214 for the fulguration of the prostatic fossa.

Modifier 59 breaks the bundle that the National Correct Coding Initiative (NCCI) imposes on 52214 and 52001, bundling 52001 into 52214, Ferragamo advises. -List 52001 first because it pays more than 52214.-  
 
Use 52648 for Laser Prostatectomy 2 Years After a TURP

Question: Our surgeon performed a laser vaporization of the prostate two years after he had performed a TURP for the same patient. Will Medicare allow us to bill 52648 two years after the carrier reimbursed us for the TURP?

Answer: Most payors do not publish any guidelines that would bar you from reporting 52648 (Laser vaporization of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed]) two years after the TURP.

Surgeons consider the laser vaporization procedure an alternative to a TURP. For the patient's initial TURP, you most likely reported 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]).

If your physician performed a second TURP more than a year after the first, you would report 52630 (Transurethral resection; of regrowth of obstructive tissue longer than one year postoperative), says Kaci Castle, CPC-OGS, coding specialist for West Physician Services in Klamath Falls, Ore. If, however, the surgeon performs a laser prostatectomy two years after the first prostatectomy, you can report 52648, unless your carrier publishes specific coding advice to the contrary.

Report Two Codes For A Two-Part (Staged) TURP

Question: Our surgeon usually performs a complete TURP procedure during the initial operative session. But recently his operative note referred to a -two part TURP,- with the first part performed a full two months before the final part. How should we code this, since the second procedure was during the global period of the first TURP?

Answer: CPT includes different codes for two-part, or staged, TURP procedures. If your surgeon usually performs TURPs during one session, you probably never noticed codes 52612 (Transurethral resection of prostate; first stage of two-stage resection [partial resection]) and 52614 (... second stage of two-stage resection [resection completed]).

You should report 52612 for the first stage and 52614-58 (Staged or related procedure or service by the same physician during the postoperative period) for the second stage TURP performed within the global period of the first.

If your operative report refers only to the second stage and the surgeon already billed the initial TURP with 52601, continue to code the second TURP with CPT code 52614-58.

To find the right TURP code every time, check out  -Make Your TURP Code Selection A Snap With This Flow Chart- on this page.

Challenge Question: Code This TURP Note

Question: Our patient had a very tight fibrosed suspensory ligament of the penis precluding adequate transurethral treatment and requiring a perineal urethrostomy. He had not responded to pharmacologic treatment, so the urologist performed the following procedure:

-I began with the PVP laser but discontinued the procedure because of an inability to adequately manipulate the instrument because of the tight suspensory ligament. Via a perineal urethrostomy and after multiple attempts I was finally able to pass only a  # 26F. Storz sheath and resectoscope. I decided then at this point to proceed with a standard TURP, resecting about 70 Grams of tissue.-

Which codes should I report for this procedure?

Answer: -When one must use more than one procedure to accomplish successful surgery, you should only report the code for the procedure that accomplishes the intended surgery,- Ferragamo says. -In this case, that would be the TURP.-

For Medicare patients, the coding policy from the NCCI is to only bill this procedure (52601). -If, however, you spent a significant amount of time performing both the PVP and the TURP, then append modifier 22 (Unusual procedural services) to 52601,- Ferra-gamo advises. Document the extra time the physician spent and submit the operative report to the insurer, along with a letter explaining the extra time and how much extra reimbursement you-re re-questing. Indicate how much longer the combined procedure (PVP and TURP) took compared to an uncomplicated TURP.

Some private insurers may allow you to report 52601 for the TURP and in addition 52648-53-59 on a second line for the PVP. Modifier 53 (Discontinued procedure) would indicate that the surgeon elected to terminate the procedure for the well being of the patient, and modifier 59 would tell the insurer that you would like separate payment for both procedures, despite the NCCI edit.

Finally, you should report 53010 (Urethrotomy or urethrostomy, external [separate procedure]; perineal urethra, external) for the external urethrostomy that the surgeon performed before the TURP.