Urology Coding Alert

A simple brushup on anatomy could mean an extra $100 of reimbursement on your next litholapaxy claim if you pay attention to the separate urinary tract sites when you read operative reports.

Every three months the Correct Coding Initiatives reduce the number of codes you can bill separately by designating codes "components" of another "comprehensive" code and sometimes these bundled component codes pay more than their comprehensive code. Here is a look at two popular urological procedures and when coders can expect reimbursement for their higher-paying component codes.

Get Paid for 52240,52318 and 50590

If you are coding transurethral resection of tumors the removal of abnormal tissue by surgery performed with an instrument inserted through the urethra you should get to know one of its components better: 52240.

When the CCI edits bundled 52240 (Cystoure-throscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; LARGE bladder tumor[s]) into 52355 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of tumor), many coders didn't realize that the formerly separately billable 52240 would pay about $50 more than its comprehensive counterpart, 52355, by the 2002 national Physician Fee Schedule. What many coders still don't realize is that 52240 can be unbundled and will yield reimbursement when coded as a procedure performed in a different and distinct site from its comprehensive service.

For example, suppose a patient was found to be bleeding from a large bladder tumor and a smaller ureteral tumor. The urologist performed a ureteroscopic transureteral tumor resection and also a transurethral resection of the bladder tumor. Because the two tumors were in different and separate locations within the urinary tract the ureter and bladder the procedures should have been coded 52355 and 52240-59. The use of modifier -59 (Distinct procedural service) would yield the full fee for the ureteral tumor resection and half for the bladder tumor resection.

Not only are the bladder resections on separate sites of the urinary tract, but the tumor resections even require separate instruments further support for urologists billing and getting paid for the procedures as separate, says Michael Hermans, MD, associate professor of surgery, division of urology for Scott & White Hospital, Clinic, Health Plan in Temple, Texas.

In a similar example, code 52318 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large [over 2.5 cm]) bundled into 52353, cystourethroscopy with lithotripsy also has a higher relative value unit (RVU) than its comprehensive code.

When this component procedure is performed with its comprehensive procedure but in different sites of the urinary tract, you can add modifier -59 to 52318 to indicate that the stone treatment was performed within the bladder while the lithotripsy (52353) was performed in the ureter. Code this scenario 52353 and 52318-59. Like procedure code 52240, 52318 is another example of a component code that pays more when billed separately than the comprehensive code with which it is bundled.

Appending modifier -59 will help lessen the discrepancy between payments for 52318 and 52353 an average nonfacility fee difference of $335, and an average facility fee difference of $138.64.

Determining when modifier -59 applies as an indicator of a procedure that was performed during another encounter with the patient at a separate time of the same day can be equally as challenging as determining when two bundled procedures are performed on separate sites.

For example, in the morning a urologist performs a ureteroscopy with lithotripsy, 52353, for a ureteral stone, and later that same day he performs an ESWL, 50590 (Lithotripsy, extracorporeal shock wave), for a renal pelvic stone. To unbundle the procedure codes and receive reimbursement for the second encounter with the patient, you must append modifier -59 to 50590.

A careful examination of each procedure code and the associated bundle by current CCI standards is a critical step in determining when a code can be unbundled and which modifiers apply for any simultaneously performed procedures.