Urology Coding Alert

Tip: Some payers may still want you to report a deleted CPT Code .

Too much money paid out for deleted code 61793 means you might be stuck with an unlisted procedure code for Cyberknife prostate treatments -- and no pay, unless you can navigate payer-specific CPT coding rules.

Turn to Unlisted Procedure Code

In the past, you reported a new prostate radiation therapy with Cyberknife technology using 61793 (Stereotactic radiosurgery [particle beam, gamma ray or linear accelerator], one or more sessions). Some payers --though not all -- were paying urologists a substantial fee for this code.

Catch: There was, however, a question of what services or work the urologist actually provided when he worked in conjunction with the radiotherapist who was providing and billing for the radiosurgery. "Whether this represented correct or proper coding, nevertheless, the CPT code used by the urologist for the urologist's initial treatment with the radiation therapist was 61793," explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook.

Unfortunately, because of this and the ambiguity of this code's definition, CPT deleted 61793 in 2009. CPT, CMS, and the American Urological Association (AUA) didn't consider 61793 to be representative of the service or work performed by the urologist, Ferragamo adds.

By default, that leaves you with only the unlisted procedure code 55899 (Unlisted procedure, male genital system) if you're going to bill for your urologist's attendance at these procedures, Ferragamo explains.

Bad news: Many payers aren't paying when urology coders use 55899 for the urologist's part in Cyberknife radiosurgery procedures for the prostate, says Gary Ronay, MD, a practicing urologist in Brandon, Fla. Medicare paid Ronay when his practice coded 61793 for the Cyberknife prostate procedures, but now that the unlisted procedure code is the only option, he is no longer getting paid.

Don't Let Non-Payment Affect Your Coding

Unfortunately, coding for some procedures hasn't kept up with technology. If no precise procedure or service code exists, you should report the service "using the appropriate unlisted procedure or service code," state CPT's Instructions for Use. CPT includes unlistedprocedure codes to allow you to report procedures for which there is no specific CPT descriptor available. When there is an established CPT code that accurately describes the services your urologist performs, you should report that code rather than an unlisted procedure code.

Whenever you file a claim using an unlisted procedure  code you should include a separate report that explains, in simple, straightforward language, exactly what the urologist did. Part of your job as a coder when coding and preparing the claim is to act as an intermediary between your physician and the claims reviewer, providing a description of the procedure in layman's terms. You may even want to include diagrams or photographs to help the person reviewing your claim to better understand the procedure your urologist performed.

Why: Your payers will consider claims with unlisted procedure codes on a case-by-case basis, and they will  determine payment to the urologist based on the documentation he provides. Unfortunately, claims reviewers frequently do not have a high level of medical knowledge, and physicians don't always dictate the most informative notes.

Be proactive: Cyberknife radiosurgery of the prostate is a good example of coding not keeping up with new technology, Ferragamo says. He suggests contacting not only your payers but also the committees that create new CPT codes. Either 55899 should be acceptable for reporting the urologist's part in the initial Cyberknife therapy, or CPT should establish a prostate-specific CPT code or prostate-specific temporary category III code for the urologist's attendance at the initial Cyberknife therapy, he adds.

"No doubt a prostate Cyberknife code would be helpful and at this time is necessary," Ronay says.

You May Still Need 61793

Some payers do not recognize unlisted procedure codes such as 55899. So what should you do in those cases? "Several private carriers and HMOs ... have suggested the continued use (for the specific carrier) of CPT code 61793," Ferragamo says, even though CPT deleted that code at the beginning of this year.

Best bet: You need to contact your payers individually and see how they want you to report your urologist's work and presence at the initial Cyberknife session.

Money matters: "Remember that the work the urologist performs for his patient at the initial treatment with Cyberknife technology usually in conjunction with the radiation oncologist within the hospital radiotherapy department or at a private radiotherapy unit is more of a medical supportive nature than either surgical or radiotherapy, and accordingly, reimbursements will be and should be on the order of an outpatient visit," Ferragamo explains.

Recent payments of $40-$50 on 55899 from Medicare and other payers reflect understanding the extent of urological care during this early session with the Cyberknife. "In the past higher payments for the urological work at that initial session were probably not warranted, and consequently led to the deletion of CPT code 61793," Ferragamo explains. "Presently, be prepared for lower urological reimbursements for the urologist who attends the initial Cyberknife therapy session."

Subscriber bonus: E-mail the editor, Leesa A. Israel, at leesai@elijournals.com with the subject line "Cyberknife Letter" to receive a free sample letter that you can use for the radiation oncologist or, less frequently, the urologist seeking authorization for Cyberknife procedures.