Urology Coding Alert

What this means: Modifier indicator "1" means that the 150 percent adjustment for bilateral procedures applies, says Jaime Cody, CPC, patient account representative for Urology of Virginia in Norfolk. If you code any of these procedures with the bilateral modifier or report them twice on the same day by any other means (for example, with -LT and -RT or with a "2" in the units field), Medicare carriers will base payment on the lower of the total actual charge for both sides, or 150 percent of the fee schedule amount for a single code.

The previous status of "0" attached to these codes prevented the 150 percent adjustment from being applied,  Cody says. Carriers based payments on the total fee schedule amount for one code, she says.

Example: The urologist performs a radical bilateral nephrectomy. You code 50230-50. Previously, you would have received reimbursement for just one code, calculated by multiplying the RVUs assigned to that code (32.18) by the conversion factor (37.8975), yielding $1,219.54 (unadjusted for geographic location).

Starting July 5, however, modifier -50 should trigger a 150 percent adjustment in the RVUs. 150 percent of 32.18 is 48.27. Multiply that by the conversion factor and you can expect to be reimbursed $1,829.31 - $609.77 more than you would have been paid for the unilateral code.

Previously, Medicare would not permit coders to append -50 to 50220 because removal of both kidneys in the same session would be a "medical impossibility/
improbability." But medical practice has proven Medicare wrong.

CMS Finally Sees Bilateral 50220 Necessity

There are cases in which a bilateral nephrectomy is necessary, such as with a patient with end-stage renal disease on hemodialysis for chronic renal failure who develops urosepsis secondary to bilateral renal abscesses, with both kidneys contracted. "In this case a bilateral nephrectomy would certainly be indicated, and now the urologist would be reimbursed for the bilateral procedure," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

"This was a very big issue for our practice," says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis. "Many of our non-Medicare payers also follow the CMS fee schedule guidelines for claim adjudication, so this was a problem most every time we filed a claim for one of these bilateral procedures." Hause was usually able to get payment after an appeal, but it was a "time-consuming and costly effort," he says. "Now that Medicare is allowing these procedures to be billed bilaterally, we can pursue getting other payers to update their systems to do so also."

Note: To download this transmittal, visit the Web site www.cms.hhs.gov/manuals/pm_trans/R558CP.pdf.

Medicare Cuts Circumcision Global

That's not all: A previous update to the fee schedule, effective since April (retroactive to Jan. 1, 2005), changes the global surgical period of 54150 (Circumcision, using clamp or other device; newborn) from 10 days to 0 days. The change allows you to report certain procedures, such as 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) or 54162 (Lysis or excision of penile post-circumcision adhesions), unmodified, as early as the day after the urologist performs 54150, says Julia Banks, CPC, coder for Eastern Urological Associates in Greenville, N.C.

Previously, a 10-day global period prevented you from reporting these bundled procedures within 10 days of each other without appending a modifier, Banks says.

Note: To download Change Request 3726, visit www.cms.hhs.gov/manuals/pm_trans/R475CP.pdf.