Urology Coding Alert

Verify that you’re following the latest guidelines.

Summertime always brings fresh rounds of coding updates for you to incorporate. The Correct Coding Initiative (CCI) edits that went into effect July 1, 2019, didn’t introduce any new bundles of note for urology practices, but there was one big change that will affect all specialties. Plus, there was a HCPCS update that you don’t want to overlook, according to Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook.

Replace BCG Code J9031

Urologists can use Bacillus Calmette-Guerin (BCG) to treat bladder tumors or bladder cancer. Your reporting of the drug changed effective July 1, 2019, when HCPCS code J9031 (BCG, intravesical) was replaced with J9030 (BCG live intravesical instillation, 1mg) for intravesical administration.

One milligram of BCG is equal to one unit from a coding perspective. The national Medicare fee rate is $2.821 per milligram. One vial of BCG contains approximately 50 mg (wet weight) lypophilized (freeze dried) powder. The vial’s national drug code (NDC) number is 0052-0602-02. Therefore, the Medicare Part B fee schedule for one full vial will be $141.05 (50 mg x 2.821).

During the recent shortage of Tice BCG, many urology offices have used a “split dosage” of BCG for multiple patients. Coding for these services has been controversial and confusing, to say the least. However, when a BCG vial is split between two patients during the same encounter, remember to code for each patient. Recent drug coding rules pertaining to the new HCPCS code J9030 suggest billing based on the number of units (mgs) used.

Example: The urologist uses 25 mg during bladder instillation. Report procedure 51720 (Bladder instillation of anticarcinogenic agent (including retention time)) with J9030 and note “25 units” in the unit column (24G) of the CMS-1500 form or equivalent EHR column.

You will also need to supply the payer with the information in the example using a drug information report submitted in box 19 of the 1500 form or in the equivalent EHR box. You should receive payment for 51720 and 25 line items of J9030.

Provide the following information on the claim:

• Name of drug: Tice BCG
• Dose administered: per milligrams up to 50 mg per vial
• Route of administration: intravesical
• National drug code number, NDCN.

Be prepared to provide a paid invoice for the BCG if your office purchased the drug and the payer requests documentation on the purchase.

Watch for New Column 1 and 2 Edit Bundling Changes

CCI edits that went into effect July 1, 2019, included a sweeping change that could often play in your favor.

Previously, CMS restricted you to appending a modifier to the Column 2 code of an edit pair (which usually is the lesser paying code of the pair) to “break” the code bundle. Effective July 1, 2019, however, you may now place the modifier on either the Column 1 or Column 2 procedure code of a Correct Code Initiative (CCI) edit pair to override the bundling edit and allow correct payment for both procedures.

Example: The urologist performs ureteroscopic fragmentation, extraction of a ureteral stone, and cystoscopic fragmentation of a large bladder stone during the same encounter.

Although CPT® code 52318 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm)) is the Column 2 code bundled into CPT® code 52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)), it is the higher paying code. To receive proper payment, report the higher-paying Column 2 code 52318 as the primary procedure without a modifier and the Column 1 code 52353 as the secondary procedure. Append either modifier 59 (Distinct procedural service) or XS (Separate structure) to 52353, depending on your payer’s requirements.

Reap the benefit: In the past, payers often paid half of the higher paying code with a modifier appended and the full fee for the lesser paying code without a modifier. This resulted in a lower payment for the services provided. Being allowed to place the modifier on either the Column 1 or Column 2 code will eliminate this incorrect reimbursement problem, Ferragamo says.

Caveat: As always, ensure that your provider’s documentation clearly supports reporting both procedure codes before you attempt to unbundle the edit with a modifier.

“If you have clear documentation of the procedures being separate from each other, you could potentially report both procedures and be reimbursed,” says coding consultant Marvel J. Hammer, RN, BS, CPC, CCS-P, ACS-PM, CPCO, of Denver, Co.