Urology Coding Alert

Hint: You should report +52442 with 52441 for each additional UroLift^® implant.

If your urologist uses a UroLift^® system to treat a patient with benign prostatic hyperplasia (BPH), you must know how many implants your urologist inserted, as well as the place of service (POS).

Don’t miss: BPH is an increase in the size of the prostate. The patient’s enlarged prostate gland will press against the urethra, and his bladder will weaken and lose the ability to completely empty urine.

Go step-by-step to always submit clean UroLift^® system claims in your practice.

Step 1: Understand What Happens During Cystourethroscopy

Urologists will usually try medications first to treat BPH. But, if medications don’t work, your urologist may turn to surgical options such as a UroLift^® system implantation.

When your urologist inserts a UroLift^® system, he performs a cystourethroscopy with insertion of one or more permanent adjustable trans-prostatic implants, also known as UroLifts^®.

Cystourethroscopy defined: “Cystourethroscopy is a minimally invasive procedure that visualizes the inside of the lower urinary tract (urethra, bladder neck, bladder, and prostate in males) to detect abnormalities or assist in transurethral surgery,” according to CPT^® Assistant Vol. 25, No. 6. “During cystourethroscopy, a cystoscope is inserted into the urethra, advanced into the bladder, and the lining of the urinary bladder and urethra is examined.”

The cystourethroscopy helps the urologist insert the UroLift^®, which “will reshape and expand the prostatic channel so that the obstruction associated with a diagnosis of BPH is reduced,” per CPT^® Assistant.

Don’t miss: A UroLift^® insertion does not involve the placement of a urethral stent, but it may involve placement of a postoperative Foley catheter for postoperative drainage in about a third of the cases.

Step 2: Rely on These Codes for UroLift^® Insertion

When your urologist performs a UroLift^® system insertion in his office, you should look to the following codes to represent your urologist’s professional fee and the cost of the implants:

• 52441 (Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant). Note: You should report 52441 to report the initial UroLift^® system implant.
• +52442 (... each additional permanent adjustable transprostatic implant (list separately in addition to code for primary procedure). Note: You should report add-on code +52442 with primary code 52441 for each additional UroLift^® implant.

Don’t miss: If your urologist performs the procedure in a facility, such as an ambulatory surgical center (ASC) or in a hospital as an inpatient or outpatient, you should report 52441 and +52442 for the professional fee, while the facility will report the implants using codes C9739 (Cystourethroscopy, with insertion of transprostatic implant; 1 to 3 implants) and C9740 (… 4 or more implants).

Coding tip: The number of implants your urologist uses is determined by the size and anatomy of the prostate observed during the initial cystourethroscopy, per CPT^® Assistant. You can report add-on code +52442 multiple times, as appropriate, for each additional implant your urologist places after the initial implant. Usually, four to six implants are needed and are payable by most payers, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.

Step 3: Don’t Forget Supporting ICD-10-CM Code

When you report 52441 and +52442 for a UroLift^® procedure, you must include the appropriate ICD-10-CM code to support medical necessity. In this case, N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms) is the correct code.

Don’t miss: Code N40.1 also includes enlarged prostate with lower urinary tract symptoms (LUTS).

Step 4: Putting it All Together With an Example

The patient has BPH that cannot be treated with medication, so the urologist performs a UroLift^® procedure. First, he advances the cystourethroscope into the urethra. Next, he determines the site of obstruction caused by the prostatic lobes and inserts a UroLift^® implant at the site. As necessary, he will insert additional implants, billing +52442 for each extra implant placed. Lastly, he performs a final scope examination of the implants and removes the cystourethroscope. The patient has an enlarged prostate with LUTS, per the medical documentation but now has an open prostatic urethra to aid in voiding.

On your claim, you should report 52441 for the insertion of a single UroLift^® implant and +52442 for each additional implant, with N40.1 as the supporting ICD-10-CM code. When obtaining authorization for a UroLift^®, remember to authorize for one implant for 52241 and for one to five stents for +52442, as the case may be dependent on the prostate size.