Urology Coding Alert

Recoup more than $200 per patient with these treatment and drug codes

With almost a half million cases estimated in the United States, chances are your office has seen its share of interstitial cystitis (IC) patients. Now you can determine whether you've been receiving adequate reimbursement for your services.

The condition, identified by ICD-9 Code 595.1 (Chronic interstitial cystitis), is also known as "painful bladder syndrome," says Heather Smolinski, CPC, coding specialist with Genito-Urinary Surgeons in Toledo, Ohio. Often, especially in the initial evaluation, patients present with symptoms such as bladder pain, urinary frequency, urgency of urination, or dysuria. But even though each of those symptoms has an ICD-9 code, "if they have a diagnosis of chronic interstitial cystitis, I would just use that," Smolinski says.

Defeat the 52260/52204 Bundle

Diagnosis: Urologists typically confirm IC by visualizing the bladder via cystourethroscopy and performing hydrodistention of the bladder, says Kelly Thomas, CPC, coding supervisor for Georgia Urology in Riverdale, Ga. If the cysto is done with general anesthesia, report CPT Code 52260 (Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction [spinal] anesthesia); if the patient is under local anesthetic, report 52265 (... local anesthesia). The urologist identifies IC by the unique look of the bladder, especially after distention revealing mucosal cracking and bleeding.

Watch out: There are a number of National Correct Coding Initiative edits involving 52260 that might cause problems for coders, Smolinski says. "Usually, we're doing [52260] to diagnose," she says. "If we suspect IC, we'll do the hydrodilation and then a biopsy." But don't expect to get reimbursed for the biopsy, she says. Code 52204 (Cystourethroscopy, with biopsy) is bundled into 52260. "We don't charge anything else out" with 52260, she says.

Strategy: "Clinically, I consider the cystoscopic examination with bladder distension and bladder biopsies to be distinct separate procedures performed at the same encounter, but not always performed together or as integral procedures," says Michael A. Ferragamo MD, FACS, clinical assistant professor of urology, State University of New York, University Hospital, Stony Brook, N.Y. Ferragamo suggests billing for both 52260 and 52204, and appending modifier -59 (Distinct procedural service) to the latter to break the bundle and indicate to the carrier that these are separate procedures. "The diagnosis for the biopsy may be ICD-9 V71.89 (Other specified suspected conditions)," Ferragamo says. "This V code is payable as a primary diagnosis. Many Medicare carriers have paid these services with the proper documentation."

Understand Installation Versus Irrigation

Treatment: A common treatment for IC, says Christopher Wayne, CPC, office manager of the Viewmont Urology Clinic in Hickory, N.C., is bladder installation, reported with 51700 (Bladder irrigation, simple, lavage and/or installation). The urologist uses a catheter to fill the patient's bladder with a therapeutic solution - often called a "bladder cocktail" - made up of various protective and healing agents. The cocktail stays in the bladder for varying amounts of time, depending on the patient's tolerance to the drugs. The bladder then drains through the catheter.

Installation is different from irrigation, another common procedure, Wayne says. "Irrigation is more of a flushing," he says, "whereas with the installation they're actually putting a drug as treatment into the bladder." Whether the urologist performs installation or irrigation, however, the CPT code to report remains the same: 51700.

Note: Catheterization codes 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) and 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]) are bundled into 51700, so don't report these catheterizations separately from bladder irrigation.

Code for Each 'Cocktail Ingredient'

Along with 51700, you can also report the HCPCS codes for the drugs used as ingredients in the cocktail, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 22-urologist practice in Indianapolis. Hause cites these frequently used installation drugs:

 

 J1212 - Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml
 

 J1644 - Injection, heparin sodium, per 1,000 units (Heparin)
 

 J2270 - Injection, morphine sulfate, up to 10 mg  (MS04)
 

 J2275 - Injection, morphine sulfate (preservative- free sterile solution), per 10 mg
 

 J3301 - Injection, triamcinolone acetonide, per 10 mg (Kenalog).

Urologists often include lidocaine jelly as an anesthetic - unfortunately, J2000, the HCPCS code for topical lidocaine, was deleted this year and the new code, J2001 (Injection, lidocaine HCl for intravenous infusion, 10 mg), is for intravenous infusion only. The result? "We're just not able to bill for that anymore," Thomas says.

To confirm IC, urologists may perform a potassium sensitivity test, installing potassium chloride (J3480, Injection, potassium chloride, per 2 mEq). "It causes pain and symptoms in patients with IC," Hause says. "The urologist instills heparin as a salvage if the patient's symptoms become intolerable."