Urology Coding Alert

The new edits also change how you code bladder instillation, kidney transplant prep, and PVR measurements

The latest Ncci Edits have the answers you have been looking for since the release of the new 2005 CPT Codes: what you can - and can't - report with all the new Fournier's debridement and kidney transplant preparation CPT codes.

The first set of National Correct Coding Initiative edits for 2005, version 11.0, includes guidance on how to report the new ureteral instillation and Fournier's debridement codes (see "CPT 2005 Update: Ring In the New Year With 3 New Fournier's Debridement Codes" in the November 2004 issue of Urology Coding Alert), as well as some surprises for ureterography injections and postvoid residual (PVR) measurements.

Reminder: These NCCI edits went into effect Jan. 1, 2005.

Break Fournier's Bundles With Modifiers

Urologists and urology coders rejoiced when they saw the new codes for debridement of Fournier's gangrene in the 2005 CPT manual. CPT codes 11004 (Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum), 11005 (... abdominal wall, with or without fascial closure) and 11006 (... external genitalia, perineum and abdominal wall, with or without fascial closure) are a vast improvement over the low-paying 11040-11044 series (Debridement; skin ...) coders were previously forced to report. The honeymoon is over, though: Codes 11004-11006 now include the following procedures, according to version 11.0:
 

 11000 - Debridement of extensive eczematous or infected skin; up to 10 percent of body surface
 

 36000 - Introduction of needle or intracatheter, vein
 

 36410 - Venipuncture, age 3 years or older, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)
 

 37202 - Transcatheter therapy, infusion other than for thrombolysis, any type (e.g., spasmolytic, vasoconstrictive)
 

 Diagnostic or therapeutic injection codes 62318-62319
 

 Nerve block injection codes 64415-64417
 

 Anesthetic agent injection codes 64425-64470 and 64475.
 
NCCI has assigned these bundles a status indicator of "1," allowing you to break the bundles with a modifier under certain clinical circumstances. Code 11006 also includes codes 11004 and 11005; those bundles are also marked with modifier indicator "1."

Exception: You may not unbundle 01995 (Regional intravenous administration of local anesthetic agent or other medication [upper or lower extremity]) from  11004-11006, because they are marked with modifier indicator "0." Codes 11004-11006 also include the operating microscope code 69990.

Adrenalectomy Included in New Backbench Code

According to the latest set of NCCI edits, the 2005 code for kidney preparation for transplant (50323, Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter[s], renal vein[s], and renal artery[s], ligating branches, as necessary), includes these two component procedures:
 

 60540 - Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy,  transabdominal, lumbar or dorsal (separate procedure)
 

 60545 - ... with excision of adjacent retroperitoneal tumor.

Why? Note that the descriptor for 50323 includes the words "excision of adrenal gland," implying that an adrenalectomy is an integral part of the backbench procedure. You may, under the proper clinical circumstances, report these codes separately; all these bundles are marked with modifier indicator "1."

The NCCI edits also affect these additional new backbench transplant preparation codes:
 

 50325 - Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal  vein(s), and renal artery(s), ligating branches, as necessary
 

 50327 - Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation;  venous anastomosis, each
 

 50328 - Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each
 

 50329 - Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each.

All of these new codes, as well as 50323, include +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]). Procedures such as these, which involve several small blood vessels, often inherently require an operating microscope, says Linda Meinhart, CPC-H, patient accounts coordinator for the Effingham Surgery Center in Effingham, Ill.

Don't miss: NCCI has marked these bundles with modifier indicator "0," preventing you from using a modifier to break the bundles under any circumstances.

Include Anesthesia in Instillation

 Code 50391 (Instillation[s] of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy tube [e.g., anticarcinogenic or antifungal agent]), also new in 2005, now includes anesthesia codes 00860 (Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; not otherwise specified) and 00862 (... renal procedures, including upper 1/3 of ureter, or donor nephrectomy).
 
Code 50391 also includes operating microscope code 69990. These bundles are marked with modifier indicator "0," which means you can never break the bundle with a modifier, regardless of the circumstances.

Resist Reporting Injections With Endoscopies

NCCI 11.0 doesn't stop at introducing bundles for new CPT codes - the new coding edits will also change how you report some existing codes. In one edit, NCCI includes 50684 (Injection procedure for ureterography or ureteropyelography through ureterostomy or indwelling ureteral catheter) in the following comprehensive codes:
 

 Renal endoscopy codes 50551-50580
 

 Ureteral endoscopy codes 50951-50980
 

 52005 - Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation or ureteropyelography, exclusive of radiologic service
 

 52007 - ... with brush biopsy of ureter and/or renal pelvis.

Thanks to previous NCCI edits, CPT code 50684 is already bundled into surgical laparoscopy codes 50947-50948 and 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) as well, says Maureen Beckwith, CPC, analyst at the University of California at San Francisco Medical Center Urology Practice.

Red flag: Along with the slew of new bundles, the new coding edits have also ordained that 52320 (Cystourethroscopy [including ureteral catheterization]; with removal of ureteral calculus) is mutually exclusive with 52330 (... with manipulation, without removal of ureteral calculus), Beckwith says. Since 52320 specifies "with removal of ureteral calculus" and 52330 specifies "without removal of ureteral calculus," by definition it would be virtually impossible for a urologist to perform both in the same session.

Note: For a complete list of new NCCI edits affecting urology coding, see "Quick Key: Get the NCCI 11.0 Rundown Here" on page 13.