Urology Coding Alert

If you perform NMP22 tests, watch for 86386 bundlings.

The Correct Coding Initiative (CCI) doesn’t take a break for summer, and you shouldn’t take a vacation from updating your coding.

In fact, in CCI version 19.2, which took effect July 1, 2013, "the number [of changes] approaches 300,000, so this one is a whopper," according to Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla.

Good news: "There were no edits between surgical procedures, present and/or new for urology," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. That means you don’t need to spend much of your valuable summer days pouring over the edits. Plus, Urology Coding Alert has made it even easier for you. Read on to see which edits you need to review.

Look to 25, 57 for New Bundle Breaking

While CCI 19.2 doesn’t add any surgical procedure bundles you need to learn, it does add many bundles that involve evaluation and management (E/M) services. Column 1 urology procedural codes 50010-55920 bundle all of the following column 2 code:

• Office/outpatient and inpatient problem-oriented E/M codes (99211-99239)
• Consultation codes (99241-92255)
• Critical care codes (99291-99292)
• Nursing care codes (99304-99316)
• Domiciliary, rest home, or custodial (assisted living) care codes (99324-99337)
• Care plan oversight code (99374-99378).

"These E/M services are also bundled into many urogynecological and neurological procedure codes seen in the gynecological and neurological sections of the 2013 CPT® manual," Ferragamo adds.

The modifier indicator for all of these edits is "1." That means you can override the bundling edits with the proper modifier in certain clinical scenarios. While the first modifier most coders think of when talking about CCI edits is modifier 59 (Distinct procedural service), the modifiers most often used to break these edits will be modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) or modifier 57 (Decision for surgery), Ferragamo says.

Labs: Pay Attention to NMP22 Edits

CCI 19.2 also adds an edit pair for column one code 86294 (Immunoassay for tumor antigen, qualitative or semiquantitative [e.g., bladder tumor antigen]) and column two code 86386 (Nuclear Matrix Protein 22 [NMP22], qualitative).

Unlike the other new lab edit pairs in version 19.2, this pair has a modifier indicator of "0," meaning that you can’t override the edit pair under any circumstances.

Distinguish bladder tumor tests: Some bladder tumor tests, such as BladderChek®, involve a qualitative urine test specifically for Nuclear Matrix Protein number 22 (NMP22). NMP22 is an abnormal protein whose presence in the urine might indicate a bladder tumor. Physicians may use the test diagnostically, or to monitor bladder cancer recurrence after treatment, Ferragamo says. You should always select the most specific code for a test, and in this case, that’s 86386.

The other code in this edit pair — 86294 — is a more general code that describes an immunoassay for tumor antigens, and may be qualitative or semi-quantitative. You would use 86294 for other immunoassay tumor antigen tests that don’t have a more specific code.

For instance, another bladder cancer test, BTA stat®, checks for a bladder tumor associated antigen that is part of the complement factor H related protein (CFHrp). This test does not check for NMP22. The correct code for this test is 86294.

Because urologists may order one or the other, but not both tests, to identify bladder tumors, CCI considers these tests "mutually exclusive."