Urology Coding Alert

If a coder enters an incorrect diagnosis code and the claim is rejected as a result, the urologist and the coder must decide how to handle the situation. Urologists should not change the diagnosis on a claim for payment after they have filed it. However, sometimes the coder notices the error when the explanation of benefits (EOB) comes back. The claim may be paid in spite of the error, or denied because of it.

If the payer denied the claim because of the diagnosis, but the diagnosis was correct, do not refile, and do not change any of your documentation. A diagnosis should not be changed for the purpose of getting payment, says Michael A. Ferragamo, MD, clinical assistant professor of urology at the State University of New York, Stonybrook. Always use the proper diagnosis and correlate it with the procedure.

Bladder Scans for Residual Urine

Not all diagnoses that apply to a patient correlate with the procedure you perform. For example, if you perform a bladder sonogram for residual urine on a Medicare patient (G0050), and use the benign prostatic hyperplasia (BPH) diagnosis code (600.0) because you see an enlarged prostate on the scan, the payer will not reimburse because the diagnosis does not support the procedure. Rather, you should code 788.21 (incomplete bladder emptying), which supports a scan done primarily to look at residual urine, or 788.20 (retention of urine, unspecified) if you performed the scan due to retention. You should note that the prostate is enlarged on your office notes, but the billing should be based on the reason for the scan, Ferragamo says.

If a claim is denied for G0050 because you have entered the wrong diagnosis, you should not necessarily refile, especially if little money is involved. But use the opportunity to educate your staff about proper diagnosis coding.

Bladder Scans for Lesions

Its easy to see why a coder could get confused a patient actually does have a certain diagnosis, but has another diagnosis as well. Which do you use for the CPT codes? Use the one that is the most appropriate. That should also be the diagnosis that gets the code paid (although some carriers allow more diagnosis codes for a certain procedure than other carriers).

For example, the urologist performs 76775 (echography, retroperitoneal [e.g., renal, aorta, nodes], B-scan and/or real time with image documentation; limited) to look at hypertrophy of the bladder wall (596.8). He or she may notice a bladder tumor during the sonogram. But even if the physician sees one, many carriers wont pay for the 76775 with a bladder tumor diagnosis. They view cystoscopy as the better study for bladder tumors. In fact, the urologist was not doing the scan for a tumor, but to evaluate bladder wall thickness or hypertrophy. In this case, bill for the hypertrophy and document the hypertrophy and the bladder tumor.

Another code recommended for bladder sonograms is 76857 (echography, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up
[e.g., for follicles]). But some carriers view 76857 as a gynecological procedure and will pay it only for a gynecological diagnosis, such as fibroids, ovarian cysts or ovarian tumors. It would not be wrong to bill 76857 with a urological diagnosis code such as bladder wall diverticula (596.3), but you might have to fight for payment. You should not change the diagnosis just to get paid, however.

If a private payer refuses to pay 76857 with your diagnoses, Ferragamo recommends trying G0050. Even though this is a Medicare code, many private payers are starting to recognize it as a urological code and will often pay for a bladder sonogram for residual urine determination with G0050.

Catheterization

In urology, a common diagnosis coding error occurs when billing catheterization. Coders file G0002 (office procedure, insertion of temporary indwelling catheter, Foley type [separate procedure]) and use incontinence (788.3x) as the diagnosis code. While a urologist may catheterize a patient who is incontinent, the procedure is for retention, not incontinence. The incontinence diagnosis would not support G0002, and the carrier would deny the claim.

TURP

If the denied claim was for a procedure with a high reimbursement, and you filed an incorrect diagnosis, change the claim to the correct diagnosis and refile. For example, a urologist performs a transurethral resection of prostate (TURP, 52601) and the claim is denied because the staff made an error and gave the diagnosis of phimosis instead of benign prostatic hyperplasia (BPH, 600.0). The fee involved is too high to lose.

You must refile the whole claim, making a note in the chart that you are doing so. Explain that you found the mistake and resubmitted the claim. Be sure to make a note of this in the medical record.

In another example, a urologist performed 55859 (transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy). The only diagnosis that supports this procedure is 185 (malignant neoplasm of prostate). There may be secondary diagnoses as well, such as hydronephrosis (591) or elevated prostate specific antigen (PSA, 790.93). Even if these conditions are present, use them as secondary, not primary, diagnoses when billing 55859. Using them as primary diagnoses would result in denial of payment.

Documentation

When you must resubmit a claim with a corrected diagnosis, follow these steps:

1. Correct the diagnosis in the medical record by crossing one line through it so it can still be read.

2. Insert the correct diagnosis.

3. Date and sign the corrections.

4. Notify the carrier that the diagnosis was in error.

5. If the payer denied the claim, and you decide to resubmit, do so on paper, with all copies of the original claim as well. Also attach documentation to verify that a simple coding error caused the denial that you were not coding the claim just to get it paid.