Urology Coding Alert

The latest version of the national Correct Coding Initiative (CCI), effective Oct. 1 to Dec. 30, 2002, can be summed up as one small step for coders, one giant leap for CMS' standard of care.

CMS reasons that once a "lesser" procedure is a regular and generally accepted part of a more extensive procedure it becomes the standard of care and is therefore incidental and not separately payable.

Version 8.3 of the CCI edits has the bundles to prove that CMS considers many injections, infusions, catheterizations and imaging procedures incidental to the vast majority of surgical specialty procedures (see "Bundles Barely Budge Urology Coding Practices" article # 3).

These edits shouldn't have much of an effect on Urology Coding , according to Robert Smith, MD, a urologist with Urology Associates in Red Bank, N.J.

The coding specialist for Urology Associates, Trudy Bouldin, agrees: "The bundling of the infusions and injections seems much more applicable to hospital urology coding" and other inpatient facilities than for office coding practices.

But there are new urology-specific comprehensive and component code pairs that will affect urology coding, including the bundling of the evacuation of clots into the anti-incontinence procedures. Beginning Oct. 1, code 52001 (Cystourethroscopy with irrigation and evacuation of clots) is bundled into 51840 (Anterior vesico-urethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple), 51841 ( complicated [e.g., secondary repair]) and 51845 (Abdomino-vaginal vesical neck suspension, with or without endoscopic control [e.g., Stamey, Raz, modified Pereyra]).

In the past, if the urologist passed a needle through the bladder during a sling procedure causing a hematuria and clots, both the sling procedure and the clot aspiration might have been billed separately, Smith says. But now the clot aspiration is considered, understandably, "part of the incontinence procedure," he says.

Also, if a physician performs evacuation of clots (52001), he can no longer bill for urethral dilation, 53600-53661, nor can he bill for the urethral catheter insertion, 53670* (Catheterization, urethra; simple) and 53675* ( complicated [may include difficult removal of balloon catheter]).

"If you are aspirating a few clots out of the catheter you have placed, the bundle makes sense because it is part of the procedure," Smith says. "But if you had to go to the operating room to pass the cystoscope to aspirate clots, I would expect that you could bill separately for it."

Smith cites an example of a patient presenting with bleeding, gross hematuria, and clots formed in the bladder that block the urethra, prohibiting urination. The urologist has to pass a catheter to drain the bladder, but if the clots are severe he may have to place a bigger catheter to aspirate the clots, which, in his opinion, should be considered a separate procedure. "Clots can complicate catheterization, making it very difficult."

Smith agrees with the bundling of urethral dilation into the evacuation of clots, "but when someone comes in with blood in their urine and the inability to urinate, the urologist treats two separate problems with two distinct procedures: the evacuation of clots and the inability to urinate, treated with 52001 and 53670 or 53675 respectively. I disagree with their bundling," he says.

However, these are implemented CCI edits that must be followed to ensure proper coding, and to code 53670 or 53675 with comprehensive code 52001 would be a failure to comply with coding guidelines, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York.

In other new edits, artificial bladder sphincter removal codes 53446 and 53448 have three new component codes bundled within them: urethrostomy codes 53000 (Urethrotomy or urethrostomy, external [separate procedure]; pendulous urethra) and 53010 ( perineal urethra, external), and meatotomy code 53020 (Meatotomy, cutting of meatus [separate procedure]; except infant). Also, 53010 and 53020 are now bundled into artificial sphincter repair codes 53447 (Removal and replacement of inflatable urethra/bladder neck sphincter including pump, reservoir, and cuff at the same operative session) and 53449 (Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff).

All of the aforementioned edits include a status modifier of 1, meaning the code pairs may be unbundled with modifier -59 (Distinct procedural service) under the appropriate circumstance when the requirements for unbundling are met.

Only two new comprehensive/component edits for urology have an indicator of 0, signifying that the bundles can't be broken using a modifier: Artificial sphincter repair codes 53446 and 53449 are bundled into 53444 (Insertion of tandem cuff [dual cuff]), and code 53449 is bundled into codes 53447 and 53448.

Four deletions of previously bundled procedures will affect urology coding. First, code 52224 (Cystourethro-scopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesion[s] with or without biopsy) is no longer bundled into 52354 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of lesion).

So if a urologist performs a cystourethroscopy with ureteroscopy to biopsy a lesion in the ureter and discovers a minor lesion in the bladder, which is subsequently removed with the cystourethroscopy, both codes can be coded together and are separately payable with modifier -51 (Multiple procedures).

In another example, if a urologist performs both a transureteral biopsy and the removal/biopsy of a small, 0.5-cm bladder lesion, both codes may be billed without bundling concerns. Coders beware: 52354 still includes 52204 (Cystourethroscopy, with biopsy) and the TURB codes, 52234-52240, with a status indicator of 1, which does allow unbundling with modifier -59 under the appropriate circumstances.

The TURB codes, 52234-52240, are no longer bundled into 52355 (Cystourethroscopy, with uretero-scopy and/or pyeloscopy; with resection of tumor). In the past, if a urologist performed a ureteroscopy with resection of a ureteral tumor at the same encounter as a TURB of a large bladder tumor, you could only code for the ureteral tumor resection, 52355, unless the circumstances warranted the unbundling of the codes using modifier -59. But now if a urologist performs that same procedure you can code 52240 and 52355-51 because the procedures are no longer bundled.

Remember that code 52240 has a higher relative value unit (RVU) than 52355, hence this becomes the principal procedure. With resection of smaller bladder tumors, the transureteral resection is sequenced first and the TUR (bladder tumor) second.

The CCI edits also designate code pairs as mutually exclusive, i.e., those services/procedures that cannot reasonably be done in the same session.

For example, a 67-year-old male patient presents with urgency and frequency of urination and is diagnosed with benign prostatic hyperplasia (BPH). The urologist decides to perform a transurethral destruction of the prostate by microwave thermotherapy, 53850 (Transurethral destruction of prostate tissue; by microwave thermotherapy), which is mutually exclusive of all other methods of transurethral destruction of prostatic tissue. In other words, 53850 can't be billed in addition to transurethral destruction of prostatic tissue by radiofrequency thermotherapy, 53852, or water-induced thermotherapy, 53853.

Per CCI instructions, mutually exclusive codes are not bundled. However, they are not to be billed together due to conflicting CPT definitions for the two codes or the "medical impossibility/improbability that the procedures could be performed at the same session." When codes identified as mutually exclusive are reported for the same patient encounter, generally only the lesser-valued procedure will be recognized and reimbursed.

CCI 8.3 includes no urology-related additions or deletions of mutually exclusive code pairs.