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Urology Coding Alert

Modifiers -62 and -80 Enhance Payment for Cystoprostatectomy With Three Surgeons

Published on Sun Jul 01, 2001

A radical cystoprostatectomy with ileocolic urinary diversion, a common urology Procedure requiring more than one physician in the operating room, demands careful coding choices. These choices determine how much each physician will be paid. In the case study below, two urologists, often partners from one practice, perform the bulk of the procedure, with the help of a general surgeon for the intestinal part of the surgery. The coding problem is: How do the two urologists and the general surgeon receive fair compensation for their respective surgical work?
 
Coding Case Study: Cystoprostatectomy With Three Surgeons
 
The patient, a 73-year-old male with recurrent carcinoma in situ of the bladder (233.7), is brought to the operating room for a radical retropubic cystoprostatectomy and ileocolic urinary diversion. Two urologists (Dr. A and Dr. B) and a general surgeon (Dr. C) remove the lymph nodes, the bladder, the prostate, seminal vesicles and the vas deferens (the radical cystoprostatectomy) and create a conduit with a loop of bowel (the ileocolic urinary diversion). 
 
Drs. A and B perform the radical retropubic cystoprostatectomy. Dr. C performs the ileocolic urinary diversion. The only code that accurately describes the combined procedure is 51595 (cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including bowel anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes).

The ileocolic urinary diversion is included in 51595, so Dr. C can use that code as well. But this case involves three surgeons. They can't all be reimbursed for 51595.
 
Using Modifier -62
 
If the case involved only two physicians, one performing the radical cystoprostatectomy and one doing the bowel loop, the best choice would be for each to bill 51595 with modifier -62 (two surgeons). Both physicians -- whether two urologists, or one urologist and one general surgeon -- would be acting as primary surgeons. The total fee for 51595 jumps to 125 percent of the fee schedule. Each surgeon files on a separate HCFA 1500 form with 51595-62, and each receives a total of 62.5 percent of the fee schedule for 51595.
 
Coders can also use modifier -62 in a case that involves three surgeons, but the third physician will not be paid because modifier -62 by definition is for two co-surgeons. The general surgeon (Dr. C) may prefer this method, as long as he or she can file 51595-62. Modifier -62, under this scenario, would benefit one of the two urologists and the general surgeon. Dr. A and Dr. C would each bill 51595-62 on separate claim forms. They share a global of 125 percent of the fee for 51595. Dr. B would not be paid.

"If you do it this way, the urologist who assisted doesn't get anything," says Michael A. Ferragamo, MD, assistant clinical professor of urology at the State University of New York, Stonybrook. But if you want to maintain a good relationship with your referring general surgeon, you might choose to allow him or her to bill the 51595-62. Since both urologists are in the same practice, they can view Dr. A's share as going into the same "pot." It seems messy, but is proper coding.
 
Tip: When using modifier -62, make sure each surgeon thoroughly documents his or her separate portion of the procedure and indicates what the other physician did.
 
Billing Modifier -80 With 44130
 
Coders can also bill with modifier -80 (assistant surgeon). Dr. A bills 51595, and Dr. B bills 51595-80. Dr. B receives 16 percent of the fee for 51595.
 
How does Dr. C -- the general surgeon -- get reimbursed with modifier -80? There is no code for isolation of the loop of bowel -- work that is included in 51595 -- which Dr. C performed. But Dr. C also connected the two ends of bowel, so in the absence of bundling, he or she could use 44130 (enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy [separate procedure]). Dr. C bills 44130 with no modifier. But, CPT and CCI bundle 44130 into 51595, so many carriers will not pay for it as a separate procedure, Ferragamo says. "Dr. C can appeal, but often he or she will not get paid."
 
Modifier -80 With Compensation to General Surgeon
 
The third option is to also use modifier -80 (Dr. A bills 51595; Dr. B bills 51595-80) and for Dr. A to pay Dr. C personally. The general surgeon needs to be compensated for his or her work. The American College of Surgeons has reviewed this problem and feels that if the general surgeon was denied payment of his or her claim because of bundling, he or she should seek compensation from the primary urologist. The urologist personally pays the general surgeon a reasonable fee.

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