Urology Coding Alert

Also watch for edit switches involving 57106.

The most recent coding edits from the National Correct Coding Initiative (CCI) went into effect on July 1, 2018. Here’s what you need to know to keep your practice’s claims on course and away from bundle-related denials.

Start With Two Particular HCPCS C Codes

Every new coding edit related to urology services includes one of two HCPCS codes introduced in 2018:

• C9738 – Adjunctive blue light cystoscopy with fluorescent imaging agent (list separately in addition to code for primary procedure)
• C9748 – Transurethral destruction of prostate tissue; by radiofrequency water vapor (steam) thermal therapy.

Remember, these C-codes are not billed by physicians or for physician offices, points out Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook. In this issue of Urology Coding Alert, information on these codes has been provided for staff members coding for in-hospital or other facility services, not for urologists or other physicians.

“Although not used for everyday physician office or facility coding, all coders should have some knowledge of HCPCS ‘C’ codes, and their particular use in the various clinical coding scenarios,” Ferragamo says.

Refresher: C-codes are used on Medicare Ambulatory Surgical center (ASC) and Hospital Outpatient Prospective Payment System (OPPS) claims, but may also be recognized on claims from other providers or other payment systems. Other facilities which also have been able to bill Medicare using the C-codes are Critical Access Hospitals (CAHs), Indian Health Service Hospital, (IHS), Hospitals in American Samoa, Guam, Saipan or the Virgin Islands. The billing of C-codes is limited to the billing for facility services, not physician services. CMS has created new HCPCS level II C codes to describe additional equipment, supplies, operating time, and other resources to allow for increased reimbursements due to procedure complexity.

Latest edits: Some edits list C9738 and C9748 as the Column 1 component of the pair; others list the codes as the Column 2 component. Modifier indicator assignment can vary as well, although most edit pairs carry a modifier of “0,” meaning you cannot append a modifier or do anything else to “break” the pair and report both codes on a single claim and expect payment for both codes.

Remember: When codes are paired together under CCI edits, and when the provider performs the services represented by both codes during the same encounter, you report the Column 1 code. That’s because CCI has determined that the services associated with the Column 2 code are an inherent part of the Column 1 code.

Watch for Times You Report C9738 Over Other Procedure

Thirteen edit pairs classify C9738 as the Column 1 reportable code. Eight represent a type of dilation procedure:

• 53600 – Dilation of urethral stricture by passage of sound or urethral dilator, male; initial
• 53601 – Dilation of urethral stricture by passage of sound or urethral dilator, male; subsequent
• 53605 – Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction (spinal) anesthesia
• 53620 – Dilation of urethral stricture by passage of filiform and follower, male; initial
• 53621 – Dilation of urethral stricture by passage of filiform and follower, male; subsequent
• 53660 – Dilation of female urethra including suppository and/or instillation; initial
• 53661 – Dilation of female urethra including suppository and/or instillation; subsequent
• 53665 – Dilation of female urethra, general or conduction (spinal) anesthesia.

The remaining five codes that are secondary to C9738 represent urethrotomy, meatotomy, and pelvic exam:

• 53000 – Urethrotomy or urethrostomy, external (separate procedure); pendulous urethra
• 53010 – … perineal urethra, external
• 53020 – Meatotomy, cutting of meatus (separate procedure); except infant
• 53025 – … infant
• 57410 – Pelvic examination under anesthesia (other than local).

Mark These Instances of C9748 as Primary

The bulk of urology edits in this edition of CCI list C9748 as the Column 1 code. CCI considers these bladder procedures to be non-reportable with C9748:

• 51102 – Aspiration of bladder; with insertion of suprapubic catheter 
• 51700 – Bladder irrigation, simple, lavage and/or instillation 
• 51701 – Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine)
• 51702 – Insertion of temporary indwelling bladder catheter; simple (eg, Foley)
• 51703 – Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon).

Seven cystoscopy and transurethral resection procedures also should not be reported with C9748:

• 52000 – Cystourethroscopy (separate procedure)
• 52001 – Cystourethroscopy with irrigation and evacuation of multiple obstructing clots
• 52281 – Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female 
• 52441 – Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant
• 52500 – Transurethral resection of bladder neck (separate procedure)
• 52630 – Transurethral resection; residual or regrowth of obstructive prostate tissue including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)  
• 52640 – … of postoperative bladder neck contracture.

In addition, you cannot report these destruction or biopsy procedures with C9748:

• 53850 – Transurethral destruction of prostate tissue; by microwave thermotherapy
• 53855 – Insertion of a temporary prostatic urethral stent, including urethral measurement
• 55700 – Biopsy, prostate; needle or punch, single or multiple, any approach
• 55706 – Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance 
• 55873 – Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring).

You will see nine code pairs that involve the same secondary/Column 2 codes as some of the edits with C9738. Do not submit these procedures with C9748, either:

• 53000
• 53010
• 53020
• 53025
• 53600
• 53601
• 53605
• 53620
• 53621.

Skip C9738, C9748 for More Comprehensive Code

You’ll find 14 code pairs that list C9738 or C9748 as the Column 2 code, or the one you don’t report.

The only edit with C9738 as the Column 2, or included, service is a bundle of 52000 (Cystourethroscopy [separate procedure]) with C9738. In the majority of instances you should submit only 52000. The pair is one of the few that carries a modifier indicator of “1,” however, so there might be times when you can append a modifier and report both procedure codes (provided you have clear documentation of why both codes can be reported and reimbursed).

If you’re able to break the coding bundle, append a modifier such as 59 (Distinct procedural service) to the Column 2 code. In this instance, that would be C9738.

The code pairs with C9748 as the Column 2 component all have a modifier indicator of “0.” Four of the edits involve TURP or laser procedures on the prostate; the codes you’ll report instead of C9748 are:

• 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)
• 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)
• 53852 – Transurethral destruction of prostate tissue; by radiofrequency thermotherapy.

The remaining pairs all have a prostatectomy procedure as the Column 1, reportable code:

• 55801 – Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy)
• 55810 – Prostatectomy, perineal radical
• 55812 – … with lymph node biopsy(s) (limited pelvic lymphadenectomy)
• 55815 – … with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes
• 55821 – Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); suprapubic, subtotal, 1 or 2 stages
• 55831 – … retropubic, subtotal
• 55840 – Prostatectomy, retropubic radical, with or without nerve sparing
• 55842 – … with lymph node biopsy(s) (limited pelvic lymphadenectomy)
• 55845 – … with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes.

Double Check Your Use of 57106

Nine changes in this edition of CCI edits now list 57106 (Vaginectomy, partial removal of vaginal wall) as the Column 2 code instead of the Column 1. Verify that you’re reporting the correct code when you’re faced with reporting 57106 with one of these procedures:

• 51597 – Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of bladder and ureteral transplantations, with or without hysterectomy and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof 
• 57107 – Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy)
• 57109 – … with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy)
• 57110 – Vaginectomy, complete removal of vaginal wall
• 57111 – … with removal of paravaginal tissue (radical vaginectomy)
• 57112 – Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy)
• 58200 – Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s)
• 58210 – Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s)  
• 58240 – Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof.

Each pair is assigned modifier indicator “0,” so don’t try to find ways to report both procedures on the same claim.

CMS plans to track the utilization and costs associated with white light/blue light cystoscopy procedure combinations that will receive a complexity adjustment, according to a blog post written by Renee Dustman, BS, AAPC MACRA Proficient, an executive editor at AAPC.

Last reminder: The HCPCS “C” codes are used only by hospitals and other facilities rather than individual physician offices. This article has been provided primarily for facility billers and coders; you only report “C” codes when billing for facilities rather than physicians.