Urology Coding Alert

But – watch for exceptions to the widespread edit pairs.

The most recent version of National Correct Coding Initiative (NCCI) edits went into effect Oct. 1, 2016, with the majority of urology procedures in the 5xxxx code family being affected. The good news from your practice’s perspective is that the changes probably won’t change much about your day-to-day reporting and coding.

Learn the Main Edit Group

A group of thirteen debridement codes are now listed as Column 2 codes in edit pairs with many primary Column 1 procedure codes found throughout the CPT^® manual.

The debridement codes in question are:

• 11000-11011 – Debridement of extensive eczematous or infected skin …
• 11004-11006 – Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection …
• 11042-11043 – Debridement, subcutaneous tissue (includes epidermis and dermis, if performed) …
• 11044-11045 – Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed) …
• +11046 – Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
• +11047 – Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure).

“When you bill one of the above debridement codes, check that this code is not bundled with another Column 1 primary code that you may also be coding,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York at Stony Brook. “Check if both codes can be billed together and if a modifier is needed on one code for payment of both.”

Example: A urologist performs a TUR(P) and also debrides a small ulcer on the scrotum. These procedure codes are bundled, but the bundle/edit can be broken with a modifier, and both services billed and paid if you have sufficient documentation. Proper coding for this scenario would include 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) for the TUR(P) and 11042-XS (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less; Separate structure) for the debridement of the scrotal ulcer.

Look to other sections of the CPT^® manual for the remaining codes that are bundled into the urology procedures. These other Column 2 codes that are bundled into the urology Column 1 codes:

• 97597 – Debridement  (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less
• 97598 – … each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
• 97602 – Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session.

 Take note, however, that the edit pairs have an assigned modifier indicator of 1, meaning that you can break the edit and report both procedures under special circumstances, but you will need detailed documentation supporting the use of both codes and the proper modifier.

Don’t Overlook the Exceptions

Although the vast majority of urology procedure codes are included in these edits, don’t make the mistake of assuming that you can never report a debridement code listed above in addition to a urology code. When you look closely, you’ll find that some procedures scattered throughout the urology section are not included in the edits.

A few examples of these exceptions include:

• 50010 – Renal exploration, not necessitating other specific procedures
• 50020 – Drainage of perirenal or renal abscess, open
• 50100 – Transection or repositioning of aberrant renal vessels (separate procedure)
• 50951 – Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service …
• 50953 – … with ureteral catheterization, with or without dilation of ureter
• 50955 – … with biopsy
• 50957 – … with fulguration and/or incision, with or without biopsy.

Take note: Just because most codes in a family are part of the edits doesn’t mean they all are. For example, 50961 (Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus) is part of the edits although the surrounding procedure codes are not.

Check for Urology/Urology Pairs

As you’re going through the edits, don’t miss a few urology/urology code pairs among the debridement edits. Each urology code is bundled with the Column 2 code 52000 (Cystourethroscopy [separate procedure]), meaning that you should not report these procedures on the same claim as 52000.

A few of the affected urology procedures include:

• 51100 – Aspiration of bladder; by needle
• 51101 – … by trocar or intracatheter
• 51102 - … with insertion of suprapubic catheter
• 52260 – Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia
• 52265 – Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia.

Takeaway: The CCI database now includes more than 1.2 million “reasons to deny a payment,” according to Frank Cohen, MPH, principal and senior analyst of The Frank Cohen Group in Spring Hill, Fla. That’s why it’s always important to delve into updates each quarter, even if they don’t seem likely to change the majority of your filing.