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Urology Coding Alert

Break Down Brachytherapy into Steps for Proper Coding and Fair Payment

Published on Wed Aug 01, 2001

Because urologists often work with radiation oncologists to perform brachytherapy, the decision of who bills for what can confuse coders. The treatment has several components, adding to the coding challenge, so Urology coders must know the specific tasks the urologist performs to gain fair reimbursement.
 
Brachytherapy is a treatment in which radioactive seeds are implanted in the prostate to treat prostate cancer. Many patients prefer this treatment to radical surgery because it takes only one day and there is less chance of urinary incontinence or penile impotence. Reflecting this patient choice, more urologists are performing procedures associated with brachytherapy.

Use 76873 for Prostate Measurement
 
Prior to seed placement, the radiation oncologist or the urologist determines the size of the prostate via transrectal ultrasound. This calculation is necessary for dosimetry -- calculating the right amount of radiation for the size of the prostate. If the urology practice has specialized sonographic equipment, often the urologist will perform the measurement. Use code 76873 (echography, transrectal; prostate volume study for brachytherapy treatment planning [separate procedure]) for this sonographic evaluation.
 
Some urology coders may want to report 76872 (echography, transrectal) for the prostate-volume measurement, but this is inaccurate. Use 76872 when you sonographically view the prostate for stones and other lesions, not for the precise measurement of prostate size needed for dosimetry.  

Coding the Seed Implantation
 
The urologist and the radiation oncologist perform the seed implantation together, each performing separate tasks. The procedure is done in the hospital or an ambulatory surgical center (ASC).
 
Coding for the procedure has several parts:
 
1. Needle placement. The urologist places the needles that will be used to implant the seeds. Report 55859 (transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy) for transperineal placement of the needles. Only the urologist will use this code because it includes cystourethroscopy, which only the urologist can perform. The cystoscopy is necessary to check if any seeds have been misplaced into the urethral lumen or bladder lumen.
 
2. Ultrasonic guidance. The urologist should bill 76965 (ultrasonic guidance for interstitial radioelement application) for ultrasonic guidance for the needle placement. Append modifier -26 (professional component) to indicate that you are performing only the professional element. Because this procedure is performed in a hospital or ASC, the facility will bill for the technical component.
 
Urologists who fail to bill for ultrasonic guidance are missing out on $70 to $100, says Michael A. Ferragamo, MD, assistant clinical professor of urology at the State University of New York, Stony Brook.
 
3. Foley catheter placement. Medicare bundles 53670* (catheterization, urethra; simple) into 55859. Coders cannot bill separately for the catheter placement for a Medicare patient, but they can report 53670* for a patient insured by a private payer. Ferragamo recommends that coders use 53670* with modifier -51 (multiple procedures) appended in addition to 55859 when billing a private payer. But not all private payers will reimburse for the Foley catheter insertion.
 
4. Seed implantation. The radiation oncologist places the seeds, and codes 77776-77778 (interstitial radiation source application). The urologist cannot use these codes. Urologists used to place the seeds themselves via an open procedure, billing 55860 (exposure of prostate, any approach, for insertion of radioactive substance) years ago, but this method lacks the preciseness and localization of newer methods, Ferragamo says. 

Coding Evaluation of Seed Placement
 
After the seeds are implanted, the urologist must make sure they are in the right place. Urologists use different methods -- cystoscopy, fluoroscopy and x-ray -- to detect whether seeds have been misplaced.
 
Cystoscopy: After the oncologist implants the seeds, the urologist performs a cystoscopy, looking into the bladder to see if there are seeds in the prostatic urethral lumen or bladder lumen. Because the cystoscopy is always performed in addition to the seed placement, it cannot be billed separately from 55859.
 
Fluoroscopy: Some urologists use fluoroscopy to determine seed symmetry in the prostate and to detect misplaced seeds. Bill 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) for this method. Coders can bill the 76000 in addition to 55859 because they are for different parts of the procedure. As of July 1, no modifier is required with 76000 (see News Briefs on page 61).
 
X-ray: Some urologists x-ray the pelvis and abdomen to evaluate radiographically the placement of seeds. Use code 74000 (radiologic examination, abdomen; single anteroposterior view) with modifier -26.

Billing for Misplaced Seeds
 
If the urologist finds misplaced seeds, he or she must remove them endoscopically with a grasping forceps. Use code 52310 (cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) for removing one seed, with modifier -51 appended. If the urologist finds and removes more than one misplaced seed, use 52315 (... complicated). Sometimes the bladder has a blood clot, and because the urologist knows the clot might contain a seed, he or she removes it with grasping forceps. Bill 52310-51 in this case.
 
Use diagnosis code 939.0 (foreign body in genitourinary tract; bladder and urethra) for misplaced seeds. Code all other procedures related to brachytherapy with 185 (malignant neoplasm of prostate).

Do Not Bill for Co-Surgery
 
Although two physicians are involved in brachy-therapy, neither needs to file with any co-surgery modifiers. "It's a combined procedure, but each physician does his own thing," Ferragamo says. "I would not recommend that the radiation oncologist and the urologist bill as co-surgeons because they each have their own specific procedures to perform." No CPT code encompasses all the work done.

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