Urology Coding Alert

Just because the operative notes mention 'laser' don't assume 52647-52649.

Many urologists are starting to use lasers, such as the Holmium laser, for a variety of prostate surgeries. But if you don't know how to dig into the operative report for the procedure details, your coding -- and ultimately, your reimbursement -- will suffer.

Skimming the report, seeing the word "Holmium" and automatically assigning the code is a recipe for disaster. Follow this expert guidance to ensure you know the laser procedure coding pitfalls and which code applies for each laser prostate treatment.

Pay Attention to Technique, Not Laser Type

Knowing that your urologist performed a prostate procedure typically leads you to three procedure codes:

• 52647 -- Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed)
• 52648 -- Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed)
• 52649 -- Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed).

How it works: You'll choose between these codes based on the technique your urologist uses and the effect the laser has on the prostate, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. As the code descriptor indicates, when you see the term "coagulation" you should report 52647; "vaporization" means 52648; and "enucleation with morcellation" leads to 52649.

Tip: "Laser coagulation of the prostate, CPT code 52647, is rarely performed today as the manufacturer has eliminated this technology from their product line," Ferragamo points out.

Keep in mind that the type of laser does not matter to your code choice. Your urologist may use the Holmium laser in a variety of prostate treatments. For example, he may use the Holmium laser to vaporize (52648) the tissue of the prostate, but also to enucleating the prostatic adenoma (52649).

Don't Assume Holmium Means 52647-52649

Just because the urologist mentions he used the laser and the procedure involved the prostate, that doesn't automatically mean codes 52647-52649 apply.

Some coders see "Holmium" mentioned in the documentation and presume the urologist performed a HoLEP (Holmium laser enucleation of the prostate) procedure and automatically report 52649, or a HoLAP (Holmium laser ablation of the prostate) procedure and automatically report 52648. But urologists are using the Holmium laser for more and more procedures, which is why you shouldn't automatically apply a code based on seeing the word "Holmium."

Example: Your urologist performs a transurethral incision of the prostate using the Holmium laser. If you were to just scan the documentation and upon seeing Holmium laser and prostate in the summary, you might be tempted to report 52647, 52648, or 52649, but none of those codes is correct.

In this case, you should use 52450 (Transurethral incision of prostate) for the procedure even though the code descriptor doesn't include mention of the Holmium laser. It does not matter what technology the urologist uses to perform the transurethral incision of the prostate (TUIP). He may use a laser, hot knife, cold knife or other technique, but you should always report 52450.

Ensure Surgeon Treats the Prostate

Codes 52647-52649 describe coagulation, vaporization, or enucleation of the prostate itself. If the urologist is not actually using the laser on prostatic tissue, but using the laser to fragment a stone lying within the prostatic urethra, for example, another code will apply.

"In layman's terms, when the physician uses a laser to coagulate, vaporize, or enucleate the prostate through an endoscope or resectoscope inserted through the urethra and the entire prostate is treated" that is when you will report 52647-52649, says Jonathan Rubenstein, MD, director of coding and physician compliance for Chesapeake Urology Associates in Baltimore.

Example: Your urologist states that he performed the "removal of a prostatic stone by use of the Holmium laser." Code 52648 deals with ablation/enucleation and the prostate so you might be tempted to assign that code for this procedure.

Catch: "CPT® 52648 does not describe the procedure that your urologist performed 'removal of prostatic stone by use of holmium laser' unless the stone was lasered and removed during the performance of laser vaporization of the total prostate, for which the lasering and removal of the stone would then not be separately billable," Rubenstein says.

There is no exact CPT® code that accurately describes the laser removal of a prostatic stone. Rather, a more appropriate code would be 52317 (Litholapaxpy, crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small [less than 2.5cm] or 52318 (... complicated or large [over 2.5 cm]) based on the stone size.

"Billing CPT® 52317 [or 52318] seems most appropriate, as it most closely describes the procedure performed and would potentially allow the reimbursement for the cost of the laser fiber used," Rubenstein explains.