Urology Coding Alert

Modifier 59 sometimes will rescue your reimbursement.

Just when you're finally getting a handle on all the 2010 coding changes, here comes round two of the Correct Coding Initiative ( CCI ) edits. Version 16.1, which took effect April 1, will tie your hands when coding many common urology procedures, including prostate biopsies and urethral dilations.

Heads up: CCI 16.1 includes 2,054 new active pairs and 1,947 modifier changes, says Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions Inc. in Clearwater, Fla.

"For urology, there will be 78 edit pair additions and two edit pair deletions," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.To ensure you get paid appropriately for your urologist's services this quarter, here's the rundown of the most important changes.

Say Goodbye to Biopsy with Several Prostate Procedures

You can no longer report prostate biopsy codes 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) or 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance) with 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]). Your payer will reimburse you for 52630 but deny the biopsy codes, and you cannot use a modifier to separate these new edits.

"I have a major issue with the bundling of 55700 and 52630," laments Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. Kater says her urologists perform a good number of prostate biopsies transrectally and 55700 is what she uses because the descriptor says "any approach." When you are performing two separate procedures utilizing two different approaches, how can they be bundled?"

Silver lining: CCI also bundles 55705 (Biopsy, prostate; incisional, any approach) into 52630, but the edit carries a "1" modifier indicator. Therefore, you can break that bundle if clinical circumstances warrant separate reporting.

Additionally: As of April 1, transurethral resection of the prostate (TURP) code 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]) and laser prostatectomy codes (52647-52649) are mutually exclusive with saturation biopsy of the prostate under anesthesia (55706).

The 52601/55706 and 52648/55706 bundles have a modifier indicator of "0" so you can never bill those codes together. On the other hand, the 52647/55706 and 52649/55706 bundles both have a modifier indicator of "1," which means you can report the codes together underspecific clinical circumstances using a modifier such as modifier 59 (Distinct procedural service), Ferragamo says.

You will also find prostate biopsy listed as a column 2 code (55706), forming mutually exclusive edits with the following column 1 codes:

Transurethral destruction of prostate tissue (53850-53852)

Prostatectomy (55801-55845, 55866)

Cryosurgical ablation of the prostate (55873).

The modifier indicator for all of these above edits is "1." You can break the bundles when clinical circumstances warrant.

Beware Multiple Urethral Dilation Edits

CCI 16.1 hits urethral dilation coding hard. You now will have to consider 53605 (Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction [spinal] anesthesia), 53620 (Dilation of urethral stricture by passage of filiform and follower, male; initial), and 53621 (Dilation of urethral stricture by passage of filiform and follower, male;subsequent) mutually exclusive with 53600 (Dilation of urethral stricture by passage of sound or urethral dilator, male; initial) and 53601 ( subsequent).

Good news: While you cannot override a portion of these edits, some of the bundles have a modifier indicator of "1." For example, CCI bundles 53601 into 53605, but assigns a "1" indicator. "This means that a patient having a dilation of a urethral stricture or bladder neck under general or spinal anesthesia in the morning may then later during that same day at another encounter have a subsequent urethral dilation under local anesthesia," Ferragamo explains. "You can report both procedures using 53605 and 53601-59."

CCI also bundles 53600 and 53601 together as a mutually exclusive pair with a modifier indicator of "1." This means that when your urologist performs a urethral dilation for a patient in the morning and then during another encounter that same afternoon performs a subsequent urethral dilation, you can report 53600 and 53601-59 and expect reimbursement for both services, Ferragamo says.

You should also add bundling edits between column 1 codes 53620 and 53621 and column 2 codes 53600, 53601, 53605, and 53621 to your updated list. These edit pairs have a modifier indicator of "0."

Female-only additions: Column 1 code 53665 (Dilation of female urethra, general or conduction [spinal] anesthesia) now forms a mutually exclusive edit pair with column 2 codes 53660 ( including suppository and/or instillation; initial) and 53661 ( subsequent). The first bundle carries a modifier indicator of "0," but the second has a modifier indicator of "1."

"This means that a female patient may undergo a urethral dilation under general or spinal anesthesia in the morning and then later that same day at another encounter undergo a urethral dilation under local anesthesia," Ferragamo says. "The coding for this scenario would be 53655 and 53661-59. Expect payment for both services."