Urology Coding Alert

Take the help of a few key authoritative sources along the way.

Prostate coagulation, vaporization, and enucleation are staple surgeries of urology practices everywhere, but that doesn’t mean that urology coders have fully mastered the often-nuanced coding dynamics behind these procedures. The ability to discern between each respective service and code means having a good grip on how the operative reports and guidelines for reporting differ among these three procedures.

Using expert advice and sprinkling in some authoritative guidance, refresh what you know about prostatic laser procedures — and clear up any lingering confusion along the way.

Review this clinical example to gain some crucial insights into the world of prostate coagulations, vaporizations, enucleations, and more.

Break Down Each Respective Coding Avenue

Example: The urologist performs an ablation of necrotic prostatic tissue using a Holmium laser. The urologist then uses a resectoscope to remove the necrotic tissue for pathological examination.

This clinical scenario intentionally does not include all the necessary details in order to convey the point that you should not code all laser therapies the same. First, consider the following three codes for prostate procedures involving the use of a laser:

• 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))

Identifying key words and techniques within the operative note is crucial in discerning between these three services. In the example above, the provider uses a Holmium laser to ablate the necrotic prostatic tissue. What’s important to consider here is that a Holmium laser can be used for both vaporization and enucleation procedures. Specifically, you may come across reports involving Holmium laser enucleation, vaporization, ablation, or even vaporesection procedures.

This scenario indicates that there’s no documentation of morcellation, but that’s not necessarily the only identifying feature you need to look out for in order to rule out a laser enucleation. From a pathological perspective, a urologist will typically perform a laser enucleation on a patient suffering from one or more urinary symptoms due to benign prostatic hyperplasia (BPH). This procedure involves fragmenting the targeted area into smaller pieces for easy removal (morcellation) after laser enucleation of a prostatic lobe.

In the example above, you may use the terms vaporization and ablation interchangeably. However, keep in mind that the technical difference between an ablation and a vaporization involves the type of Holmium laser used. That’s why you should report this clinical example with code 52648. You may also report code 52648 for other similar procedures involving photoselective vaporizations or Greenlight™ vaporizations of the prostate. Furthermore, the resection involving the resectoscope is considered a component of 52648 as per CPT^® Assistant (July 2005; Volume 15, Issue 7) guidelines and should not be separately reported.

Physician insight: “For prostatic surgery using laser technology, laser vaporization has become the procedure of choice, followed by laser enucleation and morcellation,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook. “Keep in mind that both ablations and vaporizations may be reported with 52648. If you are unable to determine the laser technology used, consult with the operating surgeon for a clearer understanding,” Ferragamo advises.

Look for Key Details to Distinguish Between 52647, 52648

Another underlying difference between codes 52647 and 52648 involves whether the laser makes direct contact with the prostatic tissue. Terminology within the operative report indicating coagulation versus vaporization is important, but without those key terms it may be tricky to discern between the respective procedures. Furthermore, keep in mind that if the underlying intent of the procedure is to coagulate the prostatic tissue, then you should not report 52648 if the surgeon vaporizes a small amount of the prostate during the coagulation procedure. CPT^® Assistant (November 2006; Volume 16, Issue 11) indicates that you should neither convert 52647 to 52648, nor report 52648 separately when the urologist performs a small amount of vaporization.

Remember: On top of never reporting a coagulation and vaporization service together, you should keep this guideline handy from the National Correct Coding Initiative (NCCI) Policy Manual: “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.”

From a documentation perspective, you should be able to clearly identify a vaporization procedure by one or more underlying traits. Following the insertion of the laser fiber into the prostatic fossa, the urologist will gradually move the laser tip across the surface of the prostate, resulting in immediate vaporization and leaving a cavity formation similar to what you might encounter in a transurethral resection of the prostate (TURP) procedure. This is fundamentally different from the coagulation, in which the laser fiber is kept at a distance in order to heat and subsequently slough the prostate.

Final note: Do not mistake the insertion of the laser fiber passed directly into the prostatic fossa as a clinical indication that code 52648 is warranted. An operative report involving a coagulation will also include a similar introduction of the laser fiber into the prostatic fossa.