Urology Coding Alert

Look out for key words in the operative report to discern between codes.

Laser treatment for benign prostate hypertrophy (BPH), adenomas, and other conditions afflicting the prostate are commonplace throughout most urology practices. But just because a particular surgery is a staple of a given specialty, you shouldn’t make the assumption that the coding fundamentals are inherently easy.

If you’ve worked your way through an operative report involving prostatic laser treatment, you can attest that there are plenty of pitfalls to trip you up if you’re not careful.

To help avoid making any critical errors, consider some of the following expert advice for accurate and compliant coding.

Distinguish Between 3 Codes

Before you dive into some coding considerations for surgeries involving prostatic laser treatment, you want to be sure your operative report meets all the necessary criteria for the respective code. That means making the proper distinctions between the following three laser treatment 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))

With the underlying similarities between these procedures, semantics within the operative report is an especially important consideration. “You’ll find that what sets apart each respective code is the probe used, the type of response of prostatic tissue to the laser used (coagulation, vaporization, or enucleation), and the method with which the surgeon destroys the prostate tissue,” explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook. For instance, consider the following instrument a surgeon may use when performing a laser coagulation of the prostate (52647):

• Laser-emitting fiber optic probe that produces a coagulation of the gland which then will require the passage of the coagulated material. This procedure is infrequently performed in today’s urological practices.

Now, distinguish those from tools a surgeon might use for laser vaporizations of prostatic tissue (52648):

• Diode side-firing fiber
• Greenlight laser

Note: This procedure is the most frequently performed of all laser treatments of the prostate gland.

Finally, a surgeon performing laser enucleation of the prostate with morcellation will include the following in their operative report:

• Holmium laser enucleation and in bladder adenoma morcellation

From a technical perspective, a holmium laser enucleation is the most difficult laser procedure for urologists to learn, master, and perform.

Coder’s note: With respect to 52649, you’ll also want to look out for documentation that supports morcellation of the prostate following laser enucleation. “Code 52649 involves the morcellation of tissue during the laser enucleation of the prostate, where the prostate tissue is then divided into small pieces to be easily removed,” outlines Becky Boone, CPC, CPMA, CEMC, CUC, Senior Urology Surgery Coder at The Coding Network, LLC. “A Holmium laser is used to remove the prostate and a separate instrument is then utilized to complete the morcellation by cutting the prostate tissue into easily removable fragments,” she adds.

Consider NCCI Policy

Now that you’ve got a better idea of what constitutes a laser prostatectomy, The National Correct Coding Initiative (NCCI) Policy Manual highlights some of the underlying rules surrounding procedures involving the destruction or removal of prostate tissue:

• “The CPT^® Manual contains many codes (CPT^® codes 52601-52649, 53850-53855, 55801-55845, 55866) which describe various methods of removing or destroying prostate tissue. These procedures are mutually exclusive, and two codes from these code ranges shall not be reported together.”

Fortunately, NCCI edits between any of the aforementioned codes reveal a modifier indicator of “0,” restricting you from submitting these claims alongside one another. If both services are performed to completion, which would be very unusual, you should omit the designated column two code.

Avoid Greenlight Vaporization Misconceptions

Succumbing to a mistaken belief surrounding a particular coding policy is one of the quickest ways to put your claims in jeopardy of both being submitted improperly and not being reimbursed. In the case of Greenlight vaporizations, there’s some confusion within the coding community surrounding the eligibility for code 52648 to be submitted more than once in a patient’s lifetime. While it’s always safe practice to confirm with each individual commercial payer, there are no known policies that restrict the submission or reimbursement of a second instance of 52648 reporting for the same patient.

Consider the following scenario: A urologist performs a follow-up Greenlight vaporization on residual prostate tissue 12 months following the initial procedure. Assuming the surgical report details a true Greenlight vaporization, you should feel confident reporting code 52648 for this second encounter.