Urology Coding Alert

Extra time evacuating clots should mean full pay - despite NCCI bundles

TURP complications can mean complications on the coder's desk, as one urology coder in Ohio discovered. The key to full and ethical reimbursement is in knowing when you're justified in breaking NCCI Edits bundles.

No matter how many coding guides, supplements and resources you collect, there's always a coding dilemma that just won't fit neatly into the scenarios described in CPT Codes or presented in the coding seminar just attended. See how our experts approach this one-of-a-kind coding conundrum and apply these concepts to your difficult cases.

The scenario: The urologist performed a 30-minute subsequent hospital visit, and then on the same day took the patient to surgery. He started out by doing a cystourethroscopy and a fulguration of bleeders and evacuating several obstructing clots. The urologist found that the prostatic fossa was bleeding from diffuse varicosities. He fulgurated those but was still unable to stop the bleeding. He then placed a Foley balloon catheter with various degrees of traction but still could not stop the bleeding.

The urologist consulted with the patient's family. The family agreed to go ahead with a transurethral resection of the prostate (TURP).

Upon completion of the bladder neck resection, the patient's urine was at first relatively clear, but the bleeding soon became heavier. Various degrees of traction and different amounts of water in the balloon were once again unable to stop the bleeding. The urologist replaced the scope but could see no discrete area of bleeding.

The urologist spoke with the family about an open procedure. He then performed a cystotomy with Bovie cautery of the prostaic fossa and evacuated the clots. The prostatic urethra appeared diffusely hemorrhagic. The urologist also placed hemostatic stitches within the prostatic fossa and packed the fossa. He then placed a Malecot catheter for suprapubic drainage, secured the tube with a Vicryl suture, and closed the cystotomy. He brought out the Malecot catheter through a separate stab incision in the fascia and skin and drained the space of Retzius. Finally, he closed the fascia and skin incision and sutured the suprapubic tube and drain in place.

Code TURP, Evacuation, Fulguration Separately

Coding solution: Your first step when tackling this challenging coding scenario is to code the subsequent hospital visit, says Sheila Gonzagowski, CPC, coder for Metro Urology in St. Paul, Minn. If the urologist decided during his examination of the patient to perform surgery on that day, append modifier -57 (Decision for surgery) to the E/M code for the subsequent hospital visit (99232, Subsequent hospital care, per day, for the evaluation and management of a patient ...), Gonzagowski says.

Even though it was not the first procedure the urologist performed, "the TURP is the primary procedure, so code that first," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook. 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]), Ferragamo says.

Next: Report 52001-59 (Cystourethroscopy with irrigation and evacuation of multiple obstructing clots; distinct procedural service) for the initial cystoscopy and evacuation of obstructing multiple clots.
 
Only use 52001 when the urologist "spends increased time evacuating bladder clots in the patient who is in clot retention, with multiple and obstructing clots," says Ferragamo. "Often this may take 30 minutes or more. Certainly in these cases the urologist should be compensated for his extra work, inasmuch as we have a code to express that work. The urologist may follow the cystoscopy and clot evacuation with a definitive procedure such as fulguration of a bleeding vessel, or a TURP, as in this case."

Caution: Don't attempt to code separately for the Foley catheter insertion. The Foley codes - 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]) and 51703 (... complicated [e.g., altered anatomy, fractured catheter/balloon]) - are both bundled into 52001 by the National Correct Coding Initiative (NCCI), says Christy Shanley, CPC, coder and billing manager for the department of urology at the University of California, Irvine. The NCCI rules state that you cannot bill 51702 or 51703 at the same time as 52001 under any circumstances, Shanley says.

Then: Report 52214-59 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra or periurethral glands; distinct procedural service) for the initial fulguration.

Break Cysto Bundles With -59

Don't miss: Modifier -59 is a must for codes 52001 and 52214, since NCCI bundles 52001 into 52214 and both 52001 and 52214 into 52601. Unlike with 51702-51703 and 52001, however, NCCI rules allow you to report these codes separately if they are distinct from the comprehensive procedures. Modifier -59 shows that in this case the cystoscopy and clot evacuation (52001) was distinct from the fulguration (52214) and that the fulguration was itself distinct from the TURP (52601).

Finally: Report 51040-59 (Cystostomy, cystotomy with drainage) for the open cystostomy, placement of the prostatic sutures, and packing, Ferragamo says. Add modifier -59 to this code because 51040 is also bundled into the TURP (52601). "Carriers should pay for this procedure separately, as the cystostomy constitutes a separate and distinct procedure in the above clinical scenario," Ferragamo says.

Result: The coding for this claim should look like this:

Line 1: 99232-57 (1 unit)
Line 2: 52601 (1 unit)
Line 3: 52001-59 (1 unit)
Line 4: 52214-59 (1 unit)
Line 5: 51040-59 (1 unit).

For Medicare you shouldn't have to worry about appending modifier -51 (Multiple procedures) to the codes on lines 2-5. Most Medicare carriers will automatically append that modifier to any procedure listed after the initial one.