Urology Coding Alert

With more than $700 per procedure on the line, keeping the physicians' roles straight is crucial

Brachytherapy presents a vexing coding scenario, thanks to the multitude of physicians who perform this service across specialties. To code correctly for this popular treatment method for prostate cancer, you have to understand which parts of the brachytherapy procedure the urologist is responsible for. Let the answers to these frequently asked questions clear up the seeds of coding confusion.

Who Does What During a Brachytherapy Procedure?

In brachytherapy, a radiation oncologist places low-dose radioactive seeds into a cancerous prostate to deliver radiation directly. Before the procedure, the oncologist measures the prostate and calculates the dosimetry of radiation. And during the procedure, the oncologist is the one who actually places the radioactive seeds, says Becky Sweat, CPC, coder and business services coordinator for the department of urology at Wake Forest University Health Services in Winston-Salem, N.C.

Using ultrasonic guidance, the urologist guides needles into the prostate through the perineum. "Then the oncologist comes in and puts the seeds in" through the needles, Sweat says. To make sure the seeds are in the right place, the urologist then visualizes the prostate through cystoscopy, fluoroscopy or x-ray.

Do this: Use 55859 (Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy) for the urologist's needle or catheter insertion, says Jennifer Vanderhorst, CPC, coder for Michigan Urological Clinic in Grand Rapids. For the ultrasonic guidance, Vanderhorst says, use 76965-26 (Ultrasonic guidance for interstitial radioelement application; professional component). Appending modifier -26 indicates that the urologist performed only the professional component. Because this procedure is performed in a hospital or ASC, the facility will bill for the technical component.

Red flag: Cystoscopy is always included in 55859, Vanderhorst says, so don't bill separately for cystoscopy to evaluate the seed placement. However, if the urologist x-rays the pelvis and abdomen, report 74000-26 (Radiologic examination, abdomen; single anteroposterior view; professional component).

Link all these procedures to ICD-9 Code 185 (Malignant neoplasm of prostate).

Should the Urologist and the Oncologist Code as Cosurgeons?

No, Sweat says. Each surgeon has his own set of specific procedures to perform, and each procedure has a CPT Codes that accurately describes the work. No single CPT code encompasses all the work done, so there's not a CPT code that two surgeons can "share."

"You cannot use either modifier -62 (Two surgeons) or modifier -80 (Assistant surgeon) with 55859," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York in Stony Brook. Medicare payment policy will not allow those modifiers appended to that procedure code. Code 55859 has "Assistant at Surgery" and "Cosurgeon" modifier indicators of "0" in the Physician Fee Schedule Database, meaning that assistant surgeons and cosurgeons will not be paid for that procedure.

Can the Urologist Code for Placing the Seeds?

It's rare that a urologist will handle and place the radioactive seeds himself. In most states, the radiation oncologist is licensed and specially trained to handle radioactive material, Ferragamo says. The oncologist reports 77776-77778 (Interstitial radiation source application) for his work.

However: "If your urologist does work alone without the radiation oncologist and performs the complete procedure of seed implantation, has had the necessary training and credentials and has the radiation licensing to handle radioactive material," Ferragamo says, "he may also charge for placing the seeds."

The supply of seeds comes from the facility where the surgeons are doing the work, Sweat says, so they are not separately billable.

What About G0256 and G0261?

These HCPCS codes, introduced in 2003, shouldn't affect how you code the urologist's work. Codes G0256 (Prostate brachytherapy using permanently implanted Palladium seeds, including transperitoneal placement of needles or catheters into the prostate, cystoscopy and application of permanent interstitial radiation source) and G0261 (Prostate brachytherapy using permanently implanted iodine seeds, including transperineal placement of needles or catheters into the prostate, cystoscopy and application of permanent interstitial radiation source) apply only to billings by hospitals or ambulatory surgical centers, Sweat says.

How Should We Code for Gold Marker Placement?

When the urologist and oncologist aren't working side-by-side, the urologist may implant gold markers into the prostate to identify the exact location and boundaries of the gland, Ferragamo says. These markers allow the oncologist to deliver full external beam radiation only to the prostate, sparing the surrounding tissues.

There is no specific code for gold marker placement, so report 53899 (Unlisted procedure, urinary system) and 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for the procedure. Append modifier -26 (Professional component) to 76942 if performed in the hospital where the urologist does not own the imaging equipment. Be sure to send your operative notes to describe and explain the unlisted procedure.

There is also no specific code for the gold markers themselves, so use 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies or materials provided]).

Problem: Medicare and most other carriers do not pay for 99070, and the markers are not cheap. You should obtain a waiver for the markers if you intend to bill the patient. In some cases, the facility's oncology department provides the markers - if so, don't code for them.