Urology Coding Alert

Coding cystoscopy is likely second nature for you because urologists frequently perform this procedure. But are you sure you're capturing every dollar your physicians deserve when they perform multiple cystoscopic examinations in one surgical session? If not, you could be leaving $150 or more on the table.

Follow this expert advice to ensure that you know when you should -- and shouldn't -- report multiple endoscopic procedures.

Cystoscopy, urethroscopy and cystourethroscopy are all endoscopic procedures. And the first question you need to ask when coding multiple endoscopic procedures during the same surgical session is: Are the endoscopies the urologist performed in the same code "family"?

Rule #1: If the answer is yes, the multiple-scope rule specifies that you cannot report the base, or "parent," code separately with a more extensive endoscopy in that same code family.

Example: Your urologist performs a cystourethroscopy (52000, Cystoure-throscopy [separate procedure]), followed by a cystourethroscopy and bladder biopsy (52204, Cystourethroscopy, with biopsy[s]). Report only 52204 because that code already includes the work described by the diagnostic cystourethroscopy code (52000). In other words, 52000 is the "parent" code and you should not report it separately.

"You will only be paid for CPT code 52204 even if billed with 52000. The carrier will deny payment for the 'base' code 52000," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, N.Y.

Note: Most private payers also follow the multiple endoscopy rule, says Jill Young, CPC-EDS, CPC-IM, of Young Medical Consulting in East Lansing, Mich. Always check your payer's guidelines to be sure. "Ask them, or bill a few claims to see how they pay," Young says.

You should always consider a diagnostic endoscopy as part of any surgical endoscopic procedure your urologist performs, according to CPT rules, says Kelly Young, a coder with Scottsdale Center for Urology in Scottsdale, Ariz. The national Correct Coding Initiative (CCI) bundles reflect this rule, Jill Young adds.

In other words, when your urologist performs multiple endoscopic procedures from the same family during the same encounter, the base or parent code (usually the diagnostic procedure) is included within the more extensive same-family procedure codes.

Rule #2: With endoscopic procedures that have the same base code, you won't receive full payment for each of the endoscopic codes. The multiple-scope rule specifies that Medicare will pay the entire fee schedule amount only for the highest-valued endoscopy in a given code family during the same operative session. Medicare will reimburse any additional endoscopies in the same family by subtracting the value of the base endoscopy from the full fee of each additional endoscopic procedure and paying the difference, Ferragamo says.

Beware: "The fee reductions for the multiple procedure rules always apply, regardless of a 'parent code,' " Kelly Young says. This means that you should sort the procedures on your claim in order from highest to lowest relative value units (RVUs). The payer then reimburses the highest-ranked procedure at 100 percent and any additional surgical procedures at 50 percent.

Example: Your urologist performs a transurethral resection of a small bladder tumor on the right lateral bladder wall and also a bladder biopsy of the left lateral wall during one surgical session. You should report 52234 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 up to 2.0 cm]) for the bladder tumor resection and also 52204 (Cystourethroscopy, with biopsy[s]) for the bladder biopsy. Append modifier 59 (Distinct procedural service) to 52204 to indicate a separately payable service. (See the article on page 28 for more on using modifier 59.)

Your payer will give you the full reimbursement for the bladder tumor resection, and the full price for the biopsy minus the fee for the base procedure (52000) for the bladder biopsy. Your payment, based on the unadjusted national Medicare Physician Fee Schedule and the 2008 conversion factor (38.0870), would look like this:

Reasoning: Payers include the value of the family base code (in this example) in each code in the family. When the physician performs multiple procedures from the same family in one session, the payer is not going to reimburse you multiple times for the value of the base code.

Your urologist may perform two endoscopic procedures in the same session whose codes are not from the same family and have different base codes. The multiple-endoscopy rule applies only if your urologist performs two or more endoscopies from the same code family. If he performs two endoscopic procedures from separate code families, you don't need to worry about this rule.

Rule #3: In such cases, when you're coding two or more procedures from different families and different base procedure codes, you may report both codes. "Expect full payment for the highest-valued procedure and half payment for the second," Ferragamo says.

Example: Your urologist performs a ureteroscopic transureteral resection of a renal pelvic tumor and during the same encounter also transurethrally resects a medium-size bladder tumor.

You should report 52355 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor) for the resection of the renal pelvic tumor, and also 52235 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) for the bladder tumor resection.

Your payer will pay you in full for the resection of the renal pelvic tumor ($500.08) and one-half of the full fee for the resection of the bladder tumor ($154.64).