Urology Coding Alert

Urologists work with neurosurgoens to treat patients with the Vocare bladder system, and due to the overlap in physicians, the coding can be confusing. But by knowing the proper coding for the preparation and followup of the procedure, urologists can be reimbursed.

Patients who have a Vocare bladder system implant or who will be getting one need a variety of pre-surgery and post-surgery procedures, particularly urodynamics studies. This device, developed and marketed by NeuroControl Corporation based in Valley View, Ohio, helps people with complete spinal cord injuries urinate on demand. (It also can be used for bowel evacuation.) Approved by the Food and Drug Administration in 1998, the Vocare bladder system is now used by 1,700 patients worldwide, according to Terri Zmina, PT, MBA, reimbursement specialist for NeuroControl, which works on products that help people with paralysis. Although the surgery itself is performed by a neurosurgeon, there is extensive preparation and followup, which is done by the urologist.

The Vocare bladder system works this way:

Internal: A receiver-stimulator, similar to a pacemaker, is implanted surgically under the skin in the abdomen by the neurosurgeon. This bladder system then sends electrical signals via electrodes to the nerves leading to the bladder and bowel. The signals cause the muscles of the bladder and urethral sphincter to contract. After the bladder contracts, the sphincter muscles relax, and the bladder empties.

External: The patient uses the system with an external controller the size of an audio cassette player. The controller, which can be stored when not in use, sends signals and power to the implant whenever bladder stimulation is needed.

The neurosurgeon does the laminectomy and implantation, but the urologist does all the screening, testing, immediate post-op, and follow-up post-op regarding the device, says Zmina.

Preoperative and Postoperative Procedures

The following billing codes are used for Vocare pre-operation procedures:

51600* (injection procedure for cystography or voiding urethrocystography)
51726 (complex cystometrogram [e.g., calibrated electronic equipment])
51741 (complex uroflowmetry [e.g., calibrated electronic equipment])
51795 (voiding pressure studies [VP]; bladder voiding pressure, any technique)
51797 (voiding pressure studies [VP]; intra-abdominal voiding pressure [AP] [rectal, gastric, intraperitoneal])


Urologists also need to know the codes for the radiological procedures done preoperatively:

76770 (echography, retroperitoneal [e.g., renal, aorta, nodes], B-scan and/or real time with image documentation; complete)

74430 (cystography, minimum of three views, radiological supervision and interpretation)

74420 (urography, retrograde, with or without KUB)

Note that the above codes, with the exception of 76770 and 74420 (both radiology codes) would be used in the urodynamics workup.

Michael Kennelly, MD, a urologist at Carolina Medical Center and the Charlotte Institute of Rehabilitation Hospital, of Charlotte, N.C., has two patients on the Vocare bladder system one had the implant done overseas and subsequently moved here, and the other was implanted under Kennellys care.

Coding a Urologists Minor Role in Surgery

The surgical procedure is a neurosurgeons procedure, explains Kennelly, noting that the bulk of the work the urologist does is preoperative assessment and postoperative management. There doesnt need to be any co-surgery, but there is a minor role that the urologist could play in the surgery itself as well.

This role involves manipulation of the device, says Kennelly. For this, you would bill 64590 (incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling). Ultimately, however, Kennelly thinks its more likely that the neurosurgeon will perform that procedure as well as the laminectomy. The surgery takes six hours, says Kennelly. The placement takes half an hour. No urologist is going to wait around for the neurosurgeon to call him for the placement and no neurosurgeon is going to want to have to wait for the urologist.

There is, however, a post-surgery procedure done while the patient is still in the hospital, which the urologist usually performs, says Kennelly. This involves reprogramming the device. The code for this procedure is 95972 (complex brain, spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programing, first hour). If it takes longer than an hour, you should bill the add-on code 95973 for each additional half hour. There also may be some reprogramming necessary during the follow-up period, which the urologist would do.

Coding Postoperative Management

For the postoperative management, the neurosurgeon follows the patient for the laminectomy, and the urologist follows the patient for the programming of the device and any urodynamics studies, explains Kennelly. I dont have any global period to worry about because I didnt do the surgery, he says. We still have to do the urology testing to make sure the patient has a compliant bladder. Because there is no global period for the urologists procedure, modifiers -54 (surgical care only) and -55 (postoperative management only) would not apply.

As for diagnosis codes, several codes could be used, says Kennelly. We use the same diagnosis code for the pre- and postoperative procedures. The actual code depends on the particular problems the patient has: 596.54 (neurogenic bladder NOS), 596.55 (detrusor sphincter dyssynergia) and 788.31 (urge incontinence) all apply.

You would not use the spinal lesion diagnosis code. For the Vocare system to work, remember that the patient must have a complete spinal cord injury. If its not complete, this system shouldnt be used, notes Kennelly. Were cutting nerves, and by the time the procedure is done, it will be complete.