Urology Coding Alert

Tip: Don't stumble into the 77xxx coding pitfall

Urologists across the country are using stereotactic radiosurgery procedures, such as the cyberknife, for prostate treatment. Your challenge becomes how to report this new technology since there is no CPT Code representing the exact procedure. Follow this expert advice to keep your coding compliant.

No Code Shouldn't Mean No Reimbursement

Stereotactic radiosurgery, also known as gamma knife surgery, requires complex planning and the efforts of a surgeon and a radiation oncologist. Usually the urologist works with a radiation oncologist administering stereotactic body radiation therapy for prostate cancer. Whenever doctors collaborate on a procedure, the potential for a coding mishap exists.

First rule: The urologist as the surgeon only bills one code -- 61793 (Stereotactic radiosurgery [particle beam, gamma ray or linear accelerator], one or more sessions), which actually appears in the neurosurgical skull/brain portion of the CPT book.

The radiation oncologist bills several codes from the 77000 series, but you shouldn't use any of these for your urologist. Some surgeons wrongly believe they can bill for 77295 (Therapeutic radiology simulation-aided field setting; 3-dimensional) or 77315 (Teletherapy, isodose plan [whether hand or computer calculated]; complex).

Caution: You can never bill for planning under your urologist, and radiation oncologists may only report one type of planning for a given session. You should report only 61793, but the radiation oncologist bills a number of codes, including the planning and dosimetry.

The problem: The CPT manual may make you second-guess your coding. "CPT procedure code 61793 is solely intent on the skull, meninges and brain, not for prostate, kidney or pancreas, based on its location in the CPT book," says Denise Stanton, CPC, CCP-P, senior coding analyst for surgical administration at Beth Israel Deaconess Medical Center.

The CPT descriptor of 61793 doesn't specify ana-tomical location, however. Therefore, you should indeed report 61793 for these procedures, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, N.Y.

Appeal to Your Payers

Some payers that used to reimburse for 61793 are beginning to deny your claims saying that this is strictly a neurological code, Ferragamo says. Other carriers, including many Medicare carriers, are still paying on this code, however.

"I think the only way to bypass these denials from those carriers who are denying now, is to speak directly to the carriers and ask them to review your claims and consider a change of their local coverage determinations (LCD) to include the prostate as a viable area for this procedure code," Ferragamo adds. See the sample appeal letter on the next page for more on how to overcome these types of denials.

"Our doctors have stopped doing the cyberknife for now until we figure out whether it is-going to be covered or not," says Kathy Peters, billing supervisor at Urology Associates Ltd. in Milwaukee, Wis. Peters found an LCD from her carrier that's in the draft stages, which is specific about which diagnosis the carrier will cover for 61793. "And lesions of the bone, adrenal, prostate, breast, uterus and ovary are not covered for primary definitive stereotactic body radiation therapy in this coverage policy," she says. "So, it looks like the committee is setting a precedent that prostate tumors are left out for this kind of treatment."

Alternative: You can try reporting an unlisted- procedure code, such as 53899 (Unlisted procedure, urinary system), instead of 61793, and you can "use the RVU value from 61793 to price the unlisted-procedure code as a comparison work value procedure code," Stanton says.

Be proactive: This is a case of coding not keeping up with new technology, Ferragamo says. He suggests contacting not only your payers but also the committees that create new CPT codes. "Either 61793 will be acceptable, or the AMA must establish a prostate-specific CPT code or prostate-specific temporary category III code just like they did with radioactive seeds."

Experts hope that the next round of new codes for 2009 will bring new radiosurgery codes, including one for prostate treatments. "We have two urology surgeons who are doing the cyberknife contouring protocol on the prostate and kidney and actually have had a general surgeon doing cyberknife on the pancreas, so it isn't just for the brain and prostate anymore," Stanton says.