Urology Coding Alert

Case Study:

Double ESWLs Do not Have to Mean Double the Headache

You may need to appeal to get proper payment.

When your urologist performs the same procedure twice during the same session, but in different anatomical areas, figuring out the proper coding can stump even the best coders. Test your know-how with this real-life case study.

Review the Surgical Case

Scenario: A patient received 3,000 shocks to a 10x8 mm stone in the right mid ureter followed by 2,000 shocks to a 7x5 mm stone in the middle calyx of the right kidney. These stones are in completely separate areas within the right urinary system.

Coding dilemma: "What would be the best way to recoup for all the work my physician actually performed on these two distinct right-sided stones?" asks Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind., who presented a similar case study.

Separate ESWLs Mean Separate Codes

Myth: For this scenario, you may think you cannot report both extracorporeal shock wave lithotripsy (ESWL) procedures.

Reality: You can code for both ESWLs on the same side using modifier 59 (Distinct procedural service) to indicate that the urologist used the same procedure for stones in different segments of the urinary tract, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Stony Brook.

In this scenario your coding should be:

• 50590 (Lithotripsy, extracorporeal shock wave) with a diagnosis of 592.0 (Calculus of kidney)

• 50590-59 with a diagnosis of 592.1 (Calculus of ureter).

Pointer: If the stones were in the left and right urinary tracts, add modifier LT for the left side and modifier RT for the right (50590-LT and 50590-59-RT).

Appeal if Payer Denies Second Code

"You may need to appeal on a denial of one part of the claim," Ferragamo says. "With an appeal and the proper documentation, you should see payment."

Tip: When you bill a complicated procedure and receive a denial that you know is unwarranted, a standard appeal may not be your best bet. You can request that the payer have a physician from your specialty review the claim and documentation.

Don't let just a payer employee or a general physician (who can be of any specialty) review your urological claim. Request that a qualified specialist, a urologist,review the appeal, because he would best understand the procedure your physician performed, the documentation,and the coding.

Bonus: Requesting a specialist is effective if the payer is denying the claim on the grounds of medical necessity as well.

"You should ask for a specialist to review any appeal, not just those denied for medical necessity," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

In your appeals letter, be specific about why you disagree with the denial of the claim and why you want a urology specialist to review your claim. Appeal statements such as "Hi. We don't agree with the denial of this claim.Please reprocess" aren't as successful as more specific appeal requests, experts say.

Tip: You should be specific as to why the procedure was medically necessary and coded properly, and thus fully payable. Include supporting documentation, such as the physician's notes.

Important: "Be sure that the op note indicates the additional time it took for both stones," says Samantha Daily, medical biller for Urologic Consultants PC in Portland, Ore. "It needs to state what the normal time is versus the actual time taken."

Good practice: Add a statement requesting a specialist review to every appeal letter you submit,Cobuzzi says. She suggests using wording such as: "Since the only physician who would be qualified to review these notes would be a urology specialist, we are requesting that these notes go to that specialist before a decision is made."

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