Urology Coding Alert

As a coder, you know all too well that every procedure is not the same. Often, you need to dig through the urologist's operative notes to select the proper codes. But even with documentation, proper code choice can prove to be a challenge with procedures such as cystoprostatectomies.

Decide which CPT codes you would choose for your urologist for this case study, shared by M. Jane Marks, billing manager at Eastern Shore Urology Associates, PA in Easton, Md., and then check your answers against the experts' answers below.

Scenario: The patient has muscle invasive bladder cancer. The urologist removed the bladder and performed an ileal conduit urinary diversion. The surgeon also removed the patient's prostate and performed a pelvic lymph node dissection, removing all obturator nodes.

The primary procedures in this case are the cystectomy, ileal conduit urinary diversion, and the node resection, all performed to treat the bladder tumor. Therefore, the first code you should report is the code that encompasses or includes all of the above procedures, namely 51595 (Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes), says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology for State University of New York, Stony Brook.

Don't forget: You should separately report the radical prostatectomy because the urologist performed that procedure, but it is not included in the 51595 code.

"A number of years ago, the American Urological Association (AUA) had indicated that you should bill for the radical prostatectomy when the urologist includes this procedure with the total cystectomy," Ferragamo explains. "Most urologists surgically remove the prostate when they perform a radical cystectomy because anatomically, the prostate is so closely associated with the bladder that performing a complete cystectomy in the male mandates that you also remove the prostate."

Use 55840 (Prostatectomy, retropubic radical, with or without nerve sparing) to report the radical prostatectomy, says Christy Shanley, CPC, CPC-URO, billing manager for the University of California, Irvine, department of urology. Append modifier 51 (Multiple procedures) to 55840 to show your carrier that the urologist performed the cystectomy and the prostatectomy during the same surgical session.

Check with your insurer first: Attaching modifier 51 to 55840 may not work with all insurers. Many carriers, including Medicare, no longer require modifier 51. Also, remember that you can expect half the global reimbursement for codes with modifier 51 attached. (Most insurance companies have adopted Medicare's policy of paying 50 percent for codes with modifier 51 attached.)

Tip: You should not bill 51595 and 55845 (Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy ...) together. The Correct Coding Initiative (CCI) bundles these two procedures, as both code descriptors include a lymphadenectomy, Shanley cautions.

There is another coding alternative that you might be tempted to consider for the cystectomy and prostatectomy -- 55845 and 51590 (Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis). In this coding scenario you would be including the lymphadenectomy with the prostatectomy instead of the bladder removal.

While the 51590/55845 combination pays about $100 more and seems like it would be proper coding, in this clinical scenario it is not. "One should never change the coding only to increase reimbursements, and you must also consider the clinical situations in this particular case," Ferragamo warns.

How it works: The urologist is performing the cystectomy to treat the bladder cancer and is removing the prostate to allow for a more radical procedure for the bladder cancer treatment, Ferragamo explains. "Remember, the node dissection is to provide a wider resection for the bladder cancer and is related to this problem. Therefore, this resection of the nodes is for the radical treatment of the bladder tumor and not for the prostate removal, and consequently should be included in the CPT code for the cystectomy if available; which it is, in CPT code 51595," he adds.

In other words: When your urologist does several procedures for a particular tumor -- in this case, the bladder tumor -- and those procedures are all included in one CPT code, you should use that CPT code. That's why you should report 51595 in this case. The 51590/55845 option sounds correct, but with 51590 and 55845 your coding is saying that the urologist performed the node dissection for the prostate, and that is not the case in this example. The urologist in this situation is treating the bladder tumor, and you should use the bladder tumor procedure code to reference the node dissection.

Alternative scenario: If the clinical circumstances were different and the urologist performed the node resection as part of a salvage radical cystoprostatectomy for recurrent advanced prostatic carcinoma rather than as treatment for a bladder cancer, you could report 55845 and 51590, Ferragamo says.

Summary: So for the case study presented here, you should report the following:

• 51595 for the complete cystectomy, ileal conduit diversion, and pelvic node resection (for the bladder tumor)

• 55840-51 for the radical prostatectomy adding to the radical nature of this procedure.