Urology Coding Alert

Since you have a HCPCS Code for robotic-assisted procedures, you should report and expect payment, right? Not so fast.

When your urologist performs a procedure using robotic technology such as the da Vinci system, payer-specific rules can complicate your coding process. Tackle your coding dilemmas with these expert tips on how to choose the right code so you get the payment your urologist deserves.

When your urologist performs a robotic-assisted laparoscopic radical prostatectomy, you will report the main procedure code (55866, Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing). But how do you capture and seek payment for the physician's technology used? The answer depends entirely on your payer.

Good news: In July 2005, HCPCS added S2900 (Surgical techniques requiring use of robotic surgical systems [list separately in addition to the code for primary procedure]). The addition gave you a code to use when your urologist used robotic equipment such as the da Vinci surgical system during procedures.

Bad news: Not all payers, including Medicare, will pay for S2900. S codes, found only in the HCPCS manual, are temporary national codes for which Medicare will not reimburse you. You may typically report S codes to some private payers and Medicaid, but double-check the rules for your particular state and payer.

"It's a mixed bag" as to which payers recognize S2900 and which ones don't, says Christy Shanley, CPC, billing manager for the University of California, Irvine, department of urology. She has reported S2900 in addition to procedure codes such as 55866, 50545 (Laparoscopy, surgical; radical nephrectomy [includes removal of Gerota's fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy]), 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy) and 57425 (Laparoscopy, surgical, colpopexy [suspension of vaginal apex]) and has successfully been paid for both codes by several HMOs on first submission (with no appeal) for the surgeon's work.

Some private payers that have paid for S2900 include Aetna, United Healthcare, Blue Cross/Blue Shield of Florida, and Keystone Healthcare in Pennsylvania, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook. For payers that recognize this S code, you can expect payments ranging from $300 to more than $1,200 for S2900, in addition to the Category I procedure code reimbursement, he adds.

For payers recognizing the S code, report the laparoscopic procedure code first and then S2900. You do not need to append a modifier to either code because S2900 is an add-on code.

Be proactive: "For private non-Medicare carriers, when you're using robotic surgical technology, report S2900 to these carriers and keep a record of which ones pay and which ones do not pay," Ferragamo says. Try appealing the first denials from a payer, explaining the existence of S2900, and that other payers are reimbursing for this HCPCS code.

When you know a payer, like Medicare, won't accept S2900, report only the main procedure code, Shanley says.

Example: Your urologist performs a laparoscopic pyeloplasty using the da Vinci surgical robotic system. For Medicare, you should report 50544 (Laparoscopy, surgical; pyeloplasty) alone. For private payers that accept S2900, you should report 50544 and S2900.

Caution: Just because a payer rejects S2900 does not mean that you should submit that code and then bill the patient when the carrier denies that part of your claim, Ferragamo says.

Tip: Avoid denials by finding out whether the payer wants S2900 or an unlisted-procedure code before your urologist performs the surgery. "When we request authorization for surgery, we include this code, too," Shanley says.

Going forward: Robotic-assisted technology is becoming more common in urology practices, so you can expect S2900 issues to cross your desk more often. "I think as urologists increasingly use this technology, we'll see more payers recognizing this code, and coders should call payer attention to this code," Ferragamo says. "They should bring the code to the attention of the various insurance carriers and tell them that there are insurances that do pay for this, noting the increased skill and training the urologist needs to use the robotics."