Urology Coding Alert

Medicare and some commercial payers will pay for multiple procedures used to reconstruct the pelvic floor. A clear understanding of these procedures, of their relationships to each other, and of Medicare bundling rules is necessary for proper coding and ethical reimbursement.

Case study: The patient's preoperative diagnosis includes stress urinary incontinence (ICD9 625.6, Stress incontinence, female), vaginal prolapse (ICD9 618.5, Prolapse of vaginal vault after hysterectomy) with a symptomatic rectocele (618.5) and cystocele (618.5), a bilateral para-vaginal defect, and a small (less than 1 cm) benign vaginal wall nodule (221.1, Benign neoplasm of other female genital organs; vagina).

The operation that she underwent was an abdominal sacrocolpopexy (57280, Colpopexy, abdominal approach) with a rectus fascia graft (20926, Tissue grafts, other [e.g., paratenon, fat, dermis]), a Burch urethropexy (51840, Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple), a bilateral paravaginal repair (57284, Paravaginal defect repair [including repair of cystocele, stress urinary incontinence, and/or incomplete vaginal prolapse]), a posterior colpor-rhaphy (57250, Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy) and rectocele repair (included in 57250), a cystocele repair (57240, Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele), excision of vaginal wall nodule (57135, Excision of vaginal cyst or tumor), and cystoscopy (52000, Cystourethroscopy [separate procedure]).

You should bill 57280 first because it has the highest relative value unit. Next report 57284 appended with modifier -51 (Multiple procedures), which includes a unilateral or bilateral paravaginal repair, the Burch procedure and the cystocele repair. List 57250-51, which includes the excision of a vaginal tumor. For the cystoscopy, use 52000-51 unless this was performed only to ensure the sutures did not enter the bladder, in which case it would be a part of the operation and not billable separately. For example, if the urologist or gynecologist performed the cystoscopy to evaluate a previously known bladder tumor, 52000 is billable. Also report 20926, which is modifier -51 exempt. The claim form should read:

Link 618.0 (Prolapse of vaginal walls without mention of uterine prolapse) and 625.6 to all procedures, with 618.0 as primary.

To arrive at the correct billing set, code every procedure as listed above, recommends Sandy Page, CPC, CCS-P, co-owner, Medical Practice Support Services, Denver. Then, look at CPT guidelines. For Medicare, also check the Correct Coding Initiative. If procedures are bundled, see if a separate reason exists for performing them; if so, unbundle with modifier -59 (Distinct procedural service) if allowable.

What is contained in the operative report determines the coding. Therefore, it's essential the report is written clearly, Page says. For example, in the operative note for this case, it was unclear that 20926 could be used, because the surgeon did not indicate that a graft came from a different place than the surgery site. "If you are a clinical person, you can read that preservation was required, and therefore know the graft was removed from its blood supply," Page says. However, this much interpretation should be unnecessary.

All the operative report says about the graft is: "The superior fascia was identified and a strip of fascia 2 cm x 10 cm long was removed after the fat was trimmed from the fascia. It was placed in moistened Ray-Tec and saline for preservation." The coder must infer that the fascia was removed and therefore "harvested" allowing 20926.

When a physician complains that a procedure wasn't charged, it's usually because the operative note was unclear. You should ask the doctor where in the report he or she states that the graft was harvested, so you'll know how to code it in the future.