Urology Coding Alert

Urologists frequently perform more than one procedure during a session, but they may not be receiving all the payment to which they are ethically entitled. To solve this problem, they should make sure to bill for all the services provided, which requires thorough documentation of each procedure.

For example, a 28-year-old woman has a one-week history of left flank pain, and a CT scan reveals a 6-mm left distal ureteral calculus. The preoperative diagnosis is left ureteral calculus, which is also the postoperative diagnosis. The operation consisted of a cystourethroscopy, left ureteral catheterization with left retrograde pyelography, left ureteroscopy, Swiss lithotripsy, stone basket extraction and insertion of an indwelling left double J stent.

During the procedure, the patient was administered general anesthesia, placed in the dorsal lithotomy position, and prepped and draped in a sterile environment. A 22 French Storz cystoscope with a 30-degree lens was then advanced. The urethra was noted as normal. The bladder was also normal, without stones, papillary tumors or other abnormalities. The left ureteral orifice was cannulated with a 5 French open-ended catheter, and a left retrograde pyelogram was performed. This demonstrated a filling defect just proximal to the extramural ureter, consistent with the 6-mm stone.

At this point, a guide wire was passed through the ureteral catheter up to the level of the renal pelvis, the ureteral catheter was removed, and balloon dilation of the ureteral orifice was performed. Following this, the cystoscope was removed leaving the guide wire in place. A 9 French tapered Wolfe rigid ureteroscope was advanced, and a calculus was identified within the distal ureter. This was grasped in a four-wire basket and pulled to the level of junction of the extra and intramural ureter, but the stone could not be brought within the intramural ureter. Therefore, the basket was disengaged, and the Swiss lithotripsy probe was advanced because the stone was fragmented within the basket. At this point, the largest fragment remaining was removed from the basket.

There were no complications with this portion of the procedure. With the stone adequately fragmented within the ureter, the ureteroscope was withdrawn. The guide wire was back loaded onto the cystoscope, and a 6x24-cm left double J stent was advanced and coiled within the left renal pelvis. This was confirmed fluoroscopically. In addition, a J hook of stent was protruding from the left ureteral orifice, which was confirmed visibly. The bladder was emptied, and the cystoscope was removed. The patient was then extubated and transported to the recovery room in stable condition.

Coding the Procedure

The main procedure and the first on the claim form should be coded 52337 (52353 in 2001) for cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included).

But that leads to the first question about this scenario. Can you bill for both methods of stone removal the basket removal and the lithotripsy? Code 52336 (52352 in 2001) is for cystourethroscopy, with ureterscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included). If this is a Medicare patient, you cannot bill the 52336 with 52337 because it is considered an integral part of the later code, explains Michael Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York Health Sciences Center in Stony Brook, N.Y. But if the patient is not a Medicare patient, he says, you can bill the 52336 with modifier -51 (multiple procedures). With Medicare, the basket extraction is bundled into the lithotripsy because the basket was used to extract the stone as part of the lithotripsy. With private payers, however, it may be paid, explains Ferragamo, who is also a urology coding consultant with PRS, a coding and reimbursement consulting firm based in Denver.

Some practices believe its good policy to always follow Medicare rules. Private payers tend to follow Medicare guidelines, says Jules Geltzeiler, MD, who practices at Shore Urology in Long Branch, N.J. We follow Medicare guidelines for everyone.

Ferragamo, however, disagrees with this. Private payers are not Medicare, and unless you know their bundling edits, I suggest billing on a fee-for-service basis. You should also ask payers for their bundling edits and review all payments to note what their edits actually are.

Although following Medicare wont get you into trouble, it may result in an unnecessary decrease in revenues.

Reading the Retrograde

The third line on the claim form is for the reading of the retrograde. Many coders may miss the opportunity to bill for this because the radiologist usually reads these films not the urologist. However, when the retrograde is taken during surgery and the radiologist isnt there, the urologist does the initial reading. Although the hospital owns the machine (and therefore can bill for the technical component), the urologist can bill 74420 (urography, retrograde, with or without KUB) with a modifier -26 to signify that he or she is billing and should be reimbursed for the professional component, or the first reading of the film.

To get paid for this reading, however, the urologist will have to set up his or her documentation a little differently, Ferragamo says. The reading should be a separate report distinct from the operating room (OR) dictation, a radiological interpretation done by the urologist, he says. Thats why Medicare and others view this as a separately reimbursable service aside from the surgical procedure.

The reading of the retrograde pyelogram during surgery is billable provided that four criteria are met, Ferragamo says: (1) the urologist does the initial reading; (2) the urologist acts on his or her reading (removes the stone); (3) the urologist writes a radiology report; and (4) the urologist appends modifier -26 to 74420.

Coding Stent Placement

The last code that should be billed for this session is 52332 (cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]). For the case presented above, modifier -51 (multiple procedures) should be appended to this code. For a Medicare patient, you should add modifier -59 (distinct procedural service) as well, indicating that this is a permanent stent and a reimbursable procedure.

Non-Medicare payers initially might not want to pay for the stent, Ferragamo says, noting that they often dont recognize modifier -59. He advises that if they dont pay, then appeal, reinforcing that it was a permanent stent and not just placed and removed at the time of surgery.

Note: This article refers to codes that have been assigned new numbers for CPT 2001. Code 52336 will be 52352, and 52337 will be 52353.