Urology Coding Alert

Look to the modifier indicator to see if you can ever break the bundles.

If your urologist performs transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence or fiducial marker placement with fluoroscopic guidance, you'll want to pay close attention to the latest bundles from the Correct Coding Initiative (CCI).

The CCI Edits released version 18.2, effective July 1, 2012, revealing 2,521 new active pairs and 88 code pair deletions, said Frank D. Cohen, MPA, MBB, senior analyst with The Frank Cohen Group, LLC, in his analysis of the changes. Of the over 2,500 new pairings, 122 had a retroactive effective date of January 1, 2012 while the remaining 2399 went into effect on July 1. All of the code bundle deletions were effective June 30.

Our experts have poured through the changes and have highlighted the ones that will potentially affect your urology practice. Here's the rundown of what you need to know now.

Skip 53860 With Urethral Reconstructions

When scanning through the CCI 18.2 edits, you'll find that the majority of the changes affecting urology procedure codes center around 53860 (Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence).

For example, urethroplasty codes 53430 (Urethroplasty, reconstruction of female urethra) and 53431 (Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence [eg, Tenago, Leadbetter procedure]) now bundle 53860.

"These edits have a modifier indicator of '1' and therefore, can be unbundled with a modifier under specific clinical circumstances," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook.

"This edit really makes sense," says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia. "Most of the time these procedures would be a part of the whole procedure being done."

Additionally: Column one code 53860 bundles the following column two codes:

• 51102 -- Aspiration of bladder; with insertion of suprapubic catheter
• 51700 -- Bladder irrigation, simple, lavage and/or instillation
• 52000 -- Cystourethroscopy
• 52001 -- Cystourethroscopy with irrigation and evacuation of multiple obstructing clots
• 52281 -- Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female
• 52285 -- Cystourethroscopy for treatment of the female urethral syndrome with any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of the bladder neck, and fulguration of polyp(s) of urethra, bladder neck, and/or trigone
• 52310 -- Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple
• 52315 -- ... complicated
• 52500 -- Transurethral resection of bladder neck (separate procedure)
• 53000-53010 -- Urethrotomy or urethrostomy, external (separate procedure) ...
• 53020-53025 -- Meatotomy, cutting of meatus (separate procedure) ..
• 53080 -- Drainage of perineal urinary extravasation; uncomplicated (separate procedure)
• 53660-53665 -- Dilation of female urethra including suppository and/or instillation ...
• P9612 -- Catheterization for collection of specimen, single patient, all places of service.

The 51700 and 53860 bundle has a modifier indicator of "0," which means the bundle can never be broken, Ferragamo warns. The other bundles have "1" modifier indicators.

"When doing a ureteral procedure the open stent is included; when doing a prostate procedure the catheter and s/p tube are included, it makes sense to include the minor urethral procedures into the main procedure," Boone says.

Watch Out for 55866 No-Nos

CCI 18.2 bundles 51800 (Open bladder neck reconstruction) with 55866 (Laparoscopic robotic assisted retropubic radical prostatectomy). This bundles has a modifier indicator of "0."

"One cannot then bill separately for an open bladder neck reconstruction when performing a robotic assisted laparoscopic retropubic radical prostatectomy," Ferragamo explains.

An indicator of "1," means that you may use a modifier to override the edit if the clinical circumstances warrant separate reimbursement, such as a separate encounter on the same date, a separate anatomical site, or a separate indication. However, a "0" indicator means that you cannot unbundle the two codes under any circumstances.

Avoid Fluoroscopy Codes With 55876

You'll also find that 55876 (Placement of fiducial markers into the prostate gland for radiation guidance) bundles fluoroscopic codes 76000 (Fluoroscopy [separate procedure], up to 1 hour physician time, other than 71023 or 71034 [eg, cardiac fluoroscopy]), 76001 (Fluoroscopy, physician time more than 1 hour, assisting a nonradiologic physician [eg, nephrostolithotomy, ...]), and 76998 (Ultrasonic guidance, intraoperative). All three bundlings carry a modifier indicator of "1," which means you can override the bundles in certain circumstances.

"This makes sense," Boone says. "In most cases, our doctors will use 76872 (Ultrasound, transrectal) and/or 76942 (Ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for the placement of the markers."

Essential tip: Do not append a modifier to override a CCI bundle just to get paid or because you do not agree with a bundle. You can use a modifier to override a bundle only if your documentation supports using the modifier.

How it works: If you determine that your urologist performed distinctly separate procedures, append modifier 59 (Distinct procedural service) to the code listed in column 2 of the CCI edits. Without modifier 59, the payer will simply apply the CCI edits and deny your claim. You should use modifier 59 to indicate that there were special circumstances that allow you to report the two codes together.