Urology Coding Alert

Plus, CCI solidifies anesthesia coding rules for the attending surgeon.

Even during the lazy days of summer, you can't let your coding update diligence slip, especially since round three of the 2010 Correct Coding Initiative edits , which took effect on July 1, will potentially wreak havoc on your indwelling ureteral stent reimbursement.

"There are 16,843 new edit pairs, bringing the total number of active edit pairs to 653,718," says Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions, Inc. in Clearwater, Fla. Take a look at the ones that will apply to your urology practice with this quick rundown.

Include Ureteral Stent Insertion With Ureteral Surgeries

The biggest change for your practice will be the bundling of column 2 code 50605 (Ureterotomy for insertion of indwelling stent, all types) into all ureteral surgical codes (50727, and 50740-50820) and all urinary diversion procedure codes (51570-51596). The modifier indicator for these edits is "1," which means you can override the bundles in certain clinical circumstances using a modifier such as 59 (Distinct procedural service).

"The new CCI edits indicate that CPT code 50605 added to the above particular procedure codes will not be a reimbursable service," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. "In the recent past the insertion of an indwelling stent after one of the above procedures was payable as an additional secondary procedure. However, with the new bundling edits noted above, 50605 will only be paid when appended with modifier 59, and only if specific criteria for use of modifier 59 are met. CPT code 50605 should not be billed routinely."

Example: Your urologist sees a patient with excessive scarring of the ureteropelvic junction (UPJ) and upper ureter, making access to the stricture difficult when performing an open pyeloplasty (50400). The urologist decides to bypass the obstructed UPJ by anastomosing the normal portion of the upper ureter to a lower pole calyx (50750, Ureterocalycostomy).

He also performs an open stent insertion during the same procedure to protect the anastomosis during healing and to drain the kidney. In the past, you would have reported 50750 (Ureterocalycostomy, anastomosis of ureter to renal calyx) and 50605.

Now, you should only report 50750 because of the CCI 16.2 bundling edits.

Example 2: Your urologist performs an ileal conduit and places J stents bilaterally to promote healing of the ureteroneoenterostomies (anastomosis of the ureters to the ileum [conduit]) and provide free drainage of the kidney. In the past, you would bill for the construction of the ileal conduit using 50820 (Ureteroileal conduit [ileal bladder ...) and 50605-50 (Bilateral procedure) for the bilateral stents. With CCI 16.2, 50605 is bundled into 50820 and now not billable as a separate procedure or service.

This edit has a modifier indicator of "1," however, so if the urologist on the same day of surgery but at another encounter decides a stent is required and places a stent via an open ureterostomy, you may then also bill for the stent insertion with 50605-59.

Skip Lidocaine and Mepavacaine With Most Procedures

Many urological codes now bundle column 2 HCPCS codes J0670 (Injection, Mepavacaine HCL, per 10 ml) and J2001 (Injection, Lidocaine HCL for intravenous infusion, 10 mg). You'll find these drug injections included in the following codes:

50021 -- Drainage of perirenal or renal abscess; percutaneous

50200 -- Renal biopsy; percutaneous, by trocar or needle

50382 -- Removal (via snare/capture) and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation

50384 -- Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation

50387 -- Removal and replacement of externally accessible transnephric ureteral stent (e.g., external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation

50389 -- Removal of nephrostomy tube, requiring fluoroscopic guidance (e.g., with concurrent indwelling ureteral stent)

50398 -- Change of nephrostomy or pyelostomy tube

50592 -- Ablation, one or more renal tumor(s), percutaneous, unilateral, radiofrequency

50593 -- Ablation, renal tumor[s], unilateral, percutaneous, cryotherapy.

The modifier indicator for these edits is "1," so you can use modifier 59 to break the bundles under appropriate clinical circumstances, Ferragamo explains.

Additionally: Other urological procedures including urodynamics (51727-51729), meatotomy (53020, 53025), excision or fulguration (53265), urethral dilations (53600-53661), minimally invasive prostatic procedure (53850-53855), penile procedures (54001, 54420), scrotal procedures (55110), as well as cryosurgical and fiducial markers (55873, 55876) also bundle codes J0670 and J2001. You'll find a modifier indicator of "1" for each of these edits.

Still more: CCI 16.2 also ties J0670 into injection code 51600, urethral catheterization codes 51701-51703, irrigation and instillation codes 51700 and 51720, aspiration of bladder codes 51100- 51102, prostate biopsy code 55700, plus several additional urological codes. (See the chart on page 52 for a full listing.) The modifier indicator for these bundles is "1" as well.

"These bundles reinforce the general Medicare coding policy that anesthesia provided by the attending physician/surgeon whether it be topical or local infiltration, is not a reimbursable service," Ferragamo explains. Consider Some Curious Facet Joint Injection Edits Most urology procedure codes from 50010 to 55920 now bundle new Category III codes 0213T (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with ultrasound guidance, cervical or thoracic; single level) and 0216T (... lumbar or sacral; single level). These edits carry a modifier indicator of "0."

Urologists don't perform facet joint injections, says Elizabeth Hollingshead, CPC, CMC, corporate billing/coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio, which makes these CCI pairings curious.

"It really seems like a strange combination," Hollingshead says. "I know that we've never done a facet joint injection. It's pretty nonsensical to me."

Reasoning: Some analysts believe that CMS is simply covering its bases to ensure that practices don't report the new T codes as a substitute for more appropriate anesthesia codes. In fact, the new Category III facet joint injection codes 0213T-0216T will be bundled into hundreds of additional codes starting in July, ranging from cardiac procedures to gastroenterology services to orthopedic procedures.