Urology Coding Alert

Trying to figure out whether a cystostomy can or cannot be coded separately with cryosurgery of the prostate often results in coders' "playing it safe" and not attempting to garner reimbursement for 51040 (Cystostomy, cystotomy with drainage) with cryosurgery.

A return to the operating room is one condition that circumvents the inclusion of many services in the cryosurgical package.

For example, a patient with carcinoma of the prostate undergoes primary treatment with cryosurgery, 55873 (Cryosurgical ablation of the prostate [includes ultrasonic guidance for interstitial cryosurgical probe placement]), in the morning. Later that day he returns to the operating room for an open cystostomy and drainage for heavy prostatic bleeding and retention.

A careful coder will recognize that the return to the operating room warrants the use of modifier -78 (Return to the operating room for a related procedure during the postoperative period) on the open cystostomy code, 51040. The coding scenario would therefore be 55873 and 51040-78.

For reimbursement purposes, coders should include a different diagnosis with the postoperative cystostomy code, says Kerry Dillon, CPC, business office manager of Greenwood Urological in Greenwood, S.C. She explains to coders that the postoperative cystostomy should be considered a complication and therefore requires complete documentation. She has observed that some urology practices perform a cystostomy with cryosurgery as a preventive measure for patients with the tendency for retention. In this situation, the cystostomy, which is included in the cryosurgery payment for Medicare purposes, would not have a separate diagnosis code because there is no diagnosis code for "a preventive service."

When a procedure typically included in 55873 is performed in the postoperative period and is considered unrelated to the original cryosurgery, coders should see the circumstances as justification for separate billing of 55873 and one of its components, like a transurethral resection (TUR).

In this second example, a patient with localized recurrent prostatic carcinoma undergoes cryosurgical ablation after failed radiation therapy. Postoperatively he does well, but after one month he requires a TUR for a bladder neck stenosis, apparently secondary to the previous radiation. A closer look at the TUR procedure reveals that this second procedure is for a problem entirely unrelated to the cryosurgical ablation of the prostate, thereby meriting the use of modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) with the appropriate TUR code, 52500-79 (Transurethral resection of bladder neck).

This example illustrates one of Medicare's requirements for coverage of cryosurgery of the prostate: a failure of radiation therapy as the primary treatment of a patient. Code 55873 is also covered by Medicare if the patients is in stage T2B or below, has a Gleason score of less than 9, and/or a PSA of less than 8 ng/mL.

A third example demonstrates how to handle reimbursement when both a urologist and a radiologist perform cryosurgery together. Suppose a urologist and a radiologist together perform cryosurgical ablation for prostatic carcinoma. The urologist performs the entire procedure with the exception of the ultrasonic placement of the probes, which is performed by the radiologist.

The correct way to code this procedure is for the urologist to bill for all of 55873 and for the radiologist to seek reimbursement directly from the urologist, says Michael A Ferragamo, MD, clinical assistant professor of urology at the State University of New York, Stony Brook. Medicare recognizes that although the two physicians may be involved, the procedures performed are usually done concurrently and should be provided by one physician.