Urology Coding Alert

Long-awaited answers to coders' questions about whether indwelling J-stents can be separately coded using modifier -59 (Distinct procedural service) have finally surfaced it turns out -59 isn't your only option.

Codes CPT 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) and 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent) are bundled into the ureteroscopic codes, 52351-52355. Thus, urology practices are not receiving sufficient reimbursement for the insertion of indwelling stents, 52332, when performed in conjunction with the ureteroscopy. That's because procedure code CPT 52332 is considered a component of ureteroscopies' global surgical packages.

Also, due to the bundling of the retrograde pyelogram, 52005, into the uretero-scopic code 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]), coders are not being reimbursed for the bilateral retrograde pyelogram procedure.

Here's a scenario in which the above factors would reduce reimbursement: A patient presents with a possible left ureteral stone and a potential right renal pelvic stone. A bilateral retrograde pyelogram confirms both stones. The physician performs a ureteroscopic extraction of the left ureteral stone without difficulty and places double J-stents bilaterally.

How can coders combat claim denials for such a case? Here's what the experts suggest.

Get Reimbursed for 52332 and 52005

The most obvious solution is to append modifier -59 to 52332 and 52005 to indicate that payers should consider the procedures separate. But this solution often results in claim denials, even though the AMA and the AUA endorse it.

Although the CCI edits have bundled 52332 into the ureteroscopy codes and many other genitourinary procedures, the AMA and AUA maintain that these self-retaining, indwelling J-stents are separately billable with the correct use of a modifier.

And surprise even CMS isn't to blame when payers deny unbundled claims. CMS "believes that the insertion of a permanent, self-retaining, indwelling stent is separately payable as CPT code 52332," says Linda S. Dietz, RHIA, CCS, CCS-P, coding specialist for the National Correct Coding Initiative. "The modifier of '1' allows modifiers associated with the NCCI, including the -59 modifier, as appropriate, to be used with the edits which bundle 52332 into 52351-52354."

Dietz cautions coders, however, to consider the global surgery modifiers -58, -78 and -79 before assuming -59 is the only suitable modifier. In fact, in the scenario presented above, modifier -50 (Bilateral procedure) is also an applicable modifier to 52332 because the stents were placed on both the right and left ureters; thus you would code the procedure 52332-50-59.

Before you append -59, be sure you have met at least one of the criteria for this modifier. According to CCI guidelines, modifier -59 applies only to circumstances in which a procedure that would normally be bundled with another procedure should not be bundled because:

Blame the Carrier

Unfortunately, carriers deny even claims that follow the above modifier guidelines. But you should stick to your guns and appeal such denials.

The confusion surrounding payment for the indwelling stent is often a result of payers' "gross lack of knowledge" of what constitutes a "permanent stent," says Morgan Hause, CCS, CCS-P, coding specialist for Urology of Indiana in Indianapolis. "If we were to leave a stent in, and not remove it or change it, we would be harming the patient; no [ureteral] stents are truly permanent."

Fortunately, coders are having some success with having their physicians write to medical directors and using their responses as evidence that indwelling/J-stents are technically considered permanent to support claims appeals, Hause adds.

A stent is considered permanent when the patient leaves the OR suite with the stent in place and the urologist plans to remove it at a later date, says Michael A. Ferragamo, MD, FACS, assistant clinical professor of urology at State University of New York, Stony Brook. And it is coders' responsibility to explain this to their carriers.

Because many coders have become accustomed to not being reimbursed for a retrograde pyelogram when it is performed in conjunction with a ureteroscopy, coders don't recognize the reimbursement potential of the retrograde pyelogram when performed bilaterally.

Typically, due to the ureteroscopy bundle, you should not be able to bill separately for the retrograde pyelogram when it's performed with a ureteroscopy due to its component status. However, remember that the right and left sides of the urinary tract are considered independent of one another. Therefore, you should code 52352 for the left ureteroscopic stone extraction, which includes the left pyelogram, and 52005-59 for the right pyelogram, a distinct procedure on a separate part of the urinary tract. Modifier -59 unbundles 52005 from 52352 under this clinical circumstance.

Code to Medicare's and Private Payers'Policies

If the commercial payers are following CPT guidelines, you may not need modifier -59 because there is nothing in the descriptions of 52352, 52005 or 52332 that would indicate a bundling of these codes.

Medicare will only reimburse one fee, whether a unilateral or bilateral cystoscopy and retrograde pyelogram are performed, but always check with your private and HMO carriers for variations of this policy. Some commercial carriers will pay extra for a bilateral pyelogram. If the carrier in fact pays for the bilateral procedure, you should code either 52005-50 or 52005-LT and 52005-50-RT.

For Medicare, you would need to code the original scenario:

For commercial carriers you would have to code the following:

*Note: Some Medicare carriers and many managed care insurances will deny 76000 when billed with other imaging codes. However, if the physician feels that the fluoroscopic imaging provides more information than is gained from the retrograde pyelogram results and supplies the necessary supporting documentation, the physician should bill 76000-26 with modifier -59 appended. "You can code 76000 in addition to your urological procedure when it is not an inherent part of the procedure that must be performed in order to perform the procedure every time," advises Margaret Lamb, RHIT, CPC, a coding professional with the Great Falls Clinic in Great Falls, Mont. Unfortunately several of these private carriers will not recognize modifier -59 and will not reimburse for this charge.