Urology Coding Alert

Hint: Be sure to check your payer's approved diagnoses.

Many urologists are using Botox to treat urinary dysfunctions in patients. With no assigned CPT Code for the work your urologist performs and varying payer policies on which diagnosis codes are acceptable for payment, just the thought of Botox injections may give you a headache.

But if you follow these four expert tips, you will find Botox coding can bring significant reimbursements for your urologist without coding headaches for you.

Your Only CPT® Choice May Be Unlisted

There is no specific CPT code for this procedure. Medicare and many other private and commercial carriers have suggested using 53899 (Unlisted procedure, urinary system) for the cystoscopy and bladder wall injections.

This coding method for Botox bladder wall injections has been suggested by CMS, and you can find the details in local coverage determinations (LCDs) from several states.

Don't over-code: "Remember that this coding includes the cystoscopy and bladder injections," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. Also, according to Medicare and CPT, the local topical anesthesia is never a billable service.

As with all unlisted codes, you should benchmark the procedure against a regular CPT^® code that has assigned RVUs. In this case, you should compare the Botox injections to 51715 (Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck) and/or 52327 (Cystourethroscopy [including ureteral catheterization]; with subureteric injection of implant material) as your benchmarks. Code 51715 pays about $293.74 in the office and $201.84 in the hospital and 52327 brings in $265.49 regardless of the place of service, Ferragamo says.

You'll need to ensure you submit a detailed operative report and documentation, along with a covering letter that explains what the urologist did, why he did it, how much you want to be paid, and the benchmarking information.

Pointer: You may also want to obtain a waiver, an advance beneficiary notice (ABN), from the patient indicating that he understands that if the payer does not reimburse you for the procedure, he will be responsible for payment. If you obtain an ABN, attach modifier GA (Waiver of liability statement on file) to 53899 to let the payer know you have a signed ABN on file for this service.

Focus on 596.54 for Medical Necessity

Urologists use Botox bladder wall injections most often for the treatment of overactive bladder syndrome. However, there are several specific urinary diagnosis codes that support medical necessity for Botox bladder wall injections, including the following ICD-9 codes:

• 596.52 -- Low bladder compliance
• 596.54 -- Neurogenic bladder NOS
• 596.55 -- Detrusor sphincter dyssynergia
• 596.59 -- Other functional disorder of bladder
• 599.82 -- Intrinsic (urethral) sphincter deficiency [ISD]
• 788.31 -- Urge incontinence
• 788.33 -- Mixed incontinence (male) (female)
• 788.34 -- Incontinence without sensory awareness.

"Recently, the FDA approved Botox for the treatment of neurogenic bladder, which has the ICD-9 code 596.54," Ferragamo says.

Key: You need to check your payer's specific LCD policy to see which diagnosis codes they will allow. For example, WPS only pays for Botox injections if the diagnosis code is 596.54.

"Before doing the injections check with the carrier for coverage of bladder injections, the fees allowed and paid, and remember to obtain authorization for that procedure," Ferragamo cautions.

Focus on 1 HCPCS Code for Type A

There are several types of Botox toxins that physicians can use. "In urology, we use Botox Type A," Ferragamo says. Type A is also known as onabotulinum (Botulinum). For this drug, report J0585 (Injection, onabotulinumtoxina, 1 unit) per unit.

"Urologists usually inject from 100 to 300 units into the bladder musculature," Ferragamo says. Urology practices purchase Botox from Allergan at a price of about $525 per 100 units vial.

Good news: Some Medicare Part B formularies may pay you for the Botox.

Best practice: In box 19 of the CMS 1500 form or its electronic equivalent, add the statement "IM injection of botulinum toxin type A into the bladder detrusor muscle." Also, now based on the new 2012 required drug information you must provide the following in box 19: the name of the drug (Botulinum toxin type A), the total dosage, the method of administration (intramuscular injection into bladder detrusor muscle), and the National Drug Code number.

Because column 24G, the units column, will only accept and allow posting of 2 digits, if you are reporting an injection of 100 units of Botox or more, you'll need to use multiple lines and attach modifier 59 (Distinct procedural service) to the second and any subsequent lines used for billing additional Botox.

How it works: So if you're billing for 100 units, record 99 units of J0585 in box 24G on one line and then report J0585-59 with a "1" in box 24G on the second line for a total of 100 units injected.

Example: In the office your urologist administers 200 units of Botox via bladder wall injection for a patient with neurogenic bladder. Your practice provides the Botox. You have obtained a signed ABN from the patient who has Medicare insurance in a state

with an LCD stating 53899 is proper coding for this service. You'll report this procedure as follows:

• 53899-GA on line 1 for the injection with diagnosis code 596.54 -- You can expect $150-$200 for this part of the claim (based on the national unadjusted rates and the 2012 conversion factor)
• J0585 on line 2 with 99 units listed in box 24G along with 596.54 as the diagnosis -- You can expect about $543 for this part of the claim
• J0585-59 on line 3 with 99 units listed in box 24G along with 596.54 as the diagnosis -- You can expect about $543 for this part of the claim
• J0585-59 on line 4 with 2 units listed in box 24G along with 596.54 as the diagnosis -- You can expect about $11 for this part of the claim.

Watch Out For Payer-Specific Guidelines

Not all payers accept the unlisted code when you are reporting Botox injections.

"Certain carriers such as Noridian, Palmetto, Capital Blue Cross in Pennsylvania, Empire Medicare of NY, Highmark Medicare of Pennsylvania and New Jersey, Aetna, and Blue Cross will all pay for the injection using the code 53899," Ferragamo says.

If a particular carrier will not accept an unlisted code, such as 53899, for Botox bladder wall injections, then in place of 53899 you should report 64640 (Destruction by neurolytic agent; other peripheral nerve or branch) and 52000 (Cystourethroscopy) with modifier 51 (Multiple procedures) attached if your payer requires that modifier. You should still use 596.54 as the diagnosis code for the neurogenic bladder condition.

Example 2: If the same patient in the example above has insurance with a payer who wants you to use 64640 and 52000, you would report the service as follows:

• 64640 on line 1 for the injection with diagnosis code 596.54
• 52000 on line 2 for the cystoscopic examination with diagnosis code 596.54
• J0585 on line 3 with 99 units listed in box 24G along with 596.54 as the diagnosis
• J0585-59 on line 4 with 99 units listed in box 24G along with 596.54 as the diagnosis
• J0585-59 on line 5 with 2 units listed in box 24G along with 596.54 as the diagnosis.

Best bet: Before your urologist performs this procedure, consult with each insurance carrier concerning the coding they prefer.