Urology Coding Alert

Watch out for CCI bundling as well -- you may need a second modifier.

When your urologist performs a procedure and two days later returns the patient back to the operating room to correct a complication, you need to know if you can report the secondary procedures, and if so, how to do so without losing money.

Scenario: A patient undergoes a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH). Initially he does well, but on postoperative day two he has severe hematuria and goes into urinary clot retention. The patient's bladder is filled with clots and the patient cannot void. The urologist returns the patient to the operating room for evacuation of clots and prostatic fossa fulguration.

Two coding questions: With this case, there are two questions you should ask before you start coding:

1. How would you code for these procedures performed within two days of each other?

2. Can you code for the cystoscopy and irrigation as well as the fulguration?

Often the cystoscopy and irrigation of the clots takes a prolonged time, longer than the fulguration would take. Find out if you can capture payment for that extra time by following three coding steps for this case study.

1. Report Just the TURP on Day One

The first procedure, the TURP, took place on a separate day so the coding is straightforward. You'll report 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) for this procedure, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

Diagnosis help: Because the urologist performed the TURP for BPH, consider the 600.00-600.21 range for the diagnosis code. When a urologist reports "benign prostatic hyperplasia," or BPH, as the diagnosis for a TURP, this diagnosis alone does not clarify which ICD-9 diagnostic code would be most appropriate for the medical necessity for this procedure.

Instead, for example, a diagnosis of "BPH with obstruction" (600.01) would be more accurate and proper diagnosis. Look for the BPH specifics and then choose from the following codes:

• 600.01 -- Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)
• 600.11 -- Nodular prostate with urinary obstruction
• 600.21 -- Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)
• 600.91 -- Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary tract symptoms (LUTS).

Note that these diagnostic ICD-9 codes include "with urinary obstruction and other lower urinary tract symptoms (LUTS)." This indicates the medical necessity for the TURP. Code 185 (Malignant neoplasm of the prostate) would be another diagnosis indicating medical necessity for a TURP.

2. Capture Cysto, Clot Evacuation, and Fulguration With 2 Codes

In this case, you can separately report the cystoscopy and irrigation as well as the fulguration, Ferragamo says. First, report 52001 (Cystourethroscopy with irrigation and evacuation of multiple obstructing clots) for the cystoscopy and evacuation of clots, Ferragamo explains. "Most important are the words "multiple obstructing clots," he adds.

Use this code for patients who are in urinary clot retention and cannot void because of clots. The diagnosis codes for 52001 in this case are 596.8 (Other specified disorders of the bladder) for the clot retention and 998.11 (Hemorrhage complicating a procedure).

Then, report 52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands) for the fulguration of prostatic fossa bleeding.

Here's why: You should report 52214 "for transurethral fulguration of prostate for postoperative bleeding within the postoperative period of a TURP (52601), a repeat TURP (52630, Transurethral resection; residual or re-growth of obstructive prostate tissue including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]), or a laser prostatectomy (52648, Laser vaporization of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed]) performed by the same physician," Ferragamo says.

You'll use diagnosis codes 599.71 (Gross hematuria) and 602.1 (Congestion or hemorrhage of prostate) for the postoperative bleeding with this procedure.

Tip: You should bill for fulguration of areas of bladder/urethral bleeding, ulcerations, or infectious lesions using 52214.

Don't miss: You need to append modifier 59 (Distinct procedural service) to 52001 to break the Correct Coding Initiative (CCI) bundle between 52001 and 52214. Bill 52001 as the primary procedure and 52214 as the secondary procedure. "This is a little unusual because the code 52001 pays more than the code into which it is bundled," Ferragamo says. The 52001 is bundled into the 52214 but the 52001 pays more than 52214, therefore, 52001-59 should be our primary surgical procedure."

3. Remember Modifier 78 During Post-Op Period

The urologist is performing the cystoscopy and fulguration in this case study during the 90-day postoperative period of the TURP procedure so you'll need a modifier. Both CPT® and Medicare consider this sort of procedure during the global period to be the treatment of a complication. Therefore, modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperativ period) is the most appropriate modifier to use.

Expect full pay: "It's interesting that when you attach modifier78 to a second procedure that is used to correct a complication of a previous surgery, and if these secondary procedures are 0-day globals as the 52001 and the 52214 are, you will be paid the full global fee," Ferragamo says. "There is no reduction when you use modifier 78 on a secondary procedure CPT® code that has a 0-day global."

Final coding: For this encounter, you'd report the following:

• 52601 on the first date of service for the TURP with diagnosis code 600.01
• 52001-78-59 on the second date of service for the cystoscopy and clot evacuation with diagnosis codes 596.8 and 998.11
• 52214-78 on the second date of service for the fulguration with diagnosis codes 599.71 and 602.1.