Urology Coding Alert

Bonus: Handle all the latest coding edits with this
comprehensive rundown

Just when you've got all the new CPT Codes and the January edition of the National Correct Coding Initiative edits under your belt, here comes round two of the NCCI Edits .

Good news: We've done the work for you. Here is a rundown of the most important additions and deletions in version 13.1, which took effect on April 1.

Skip Modifier 59 for 52320, 52330 and 52341-52354

 CMS has removed the bundling of 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) into 52351-52354 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy ...) retroactively to Jan. 1 of this year, according to the edits now on the CMS Web site (www.cms.hhs.gov/
NationalCorrectCodInitEd/NCCIEP). You can now submit 52332 with these codes to Medicare without appending modifier 59 (Distinct procedural service), says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis.
 
"This will help providers from hitting utilization outliers for modifier 59 use, which can cause educational letters and audits if used too much," Hause adds.

NCCI version 13.1 also deletes the bundles between 52332 and 52320 (Cystourethroscopy [including ureteral catheterization]; with removal of ureteral calculus) and 52330 (... with manipulation, without removal of ureteral calculus).

Caution: Check with your other non-Medicare payers before eliminating modifier 59 on claims that have 52332 billed with 52320, 52330 and 52351-52354. Other carriers "are notorious for implementing new edits as they are added by CMS, but neglect to remove them when CMS does so," Hause says. You may need to continue to use modifier 59 on 52332 for commercial payers.

Tip: If you would like, you can append modifier 51 (Multiple procedures) when you report 52332 with 52351-52355 to indicate that the urologist performed the two procedures during the same operative session, but it is not required for Medicare claims.

Watch New Urogynecology Bundlings

You can no longer bill a female pelvic examination under anesthesia with a cystoscopic examination. NCCI 13.1 bundles 57410 (Female pelvic examination under anesthesia) into cystoscopy codes 52000-52400 and also into codes 57283 (Colpopexy, vaginal; intraperitoneal approach [uterosacral, levator myorrhaphy]) and 57295 (Revision [including removal] of prosthetic vaginal graft; vaginal approach).

You cannot overcome these edits with any modifier, because they have a modifier indicator of "0," says Michael A. Ferragamo, MD, FACS, clinical assistant professor at State University of New York, Stony Brook.

How it works: A modifier indicator of "0" means that you cannot bypass or break an edit pair with any modifier. A "1" modifier indicator means it may be appropriate to "unbundle" the codes using a modifier when appropriate (for instance, different site, separate encounter).
 Several codes are now bundled with 57295 (Revision [including removal] of prosthetic vaginal graft; vaginal approach):

• 51701 -- Insertion of non-indwelling bladder catheter (e.g., straight catheterization for residual urine)

• 51702 -- Insertion of temporary indwelling bladder catheter; simple (e.g., Foley)

• 56810 -- Perineoplasty, repair of perineum, nonobstetrical (separate procedure)

• 57100 -- Biopsy of vaginal mucosa; simple (separate procedure)

• 57180 -- Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage (separate procedure)

• 57400 -- Dilation of vagina under anesthesia

• 57415 -- Removal of impacted vaginal foreign body (separate procedure) under anesthesia

• 57420 -- Colposcopy of the entire vagina, with cervix if present

• 57452 -- Colposcopy of the cervix including upper/adjacent vagina

• 57500 -- Biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)

• 57800 -- Dilation of cervical canal, instrumental (separate procedure)

• 58100 -- Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure).

The first three bundles (51701, 51702 and 56810) have a modifier indicator of "0" so you cannot use a modifier to overcome the new edits. The other new 57295 bundles, however, have a modifier indicator of "1," meaning you can override the edits with a modifier when appropriate.

Eliminate Several Procedures With Ureteral Stent Removal/Replacement

NCCI version 13.1 bundles the following procedures into removal/replacement (50382) and removal (50384) of an internal ureteral stent, Ferragamo says:

• Removal and replacement of externally accessible ureteral stent (50387)

• Injection of renal pelvis (50390)

• Percutaneous nephrostomy and radiological supervision (50392, 74475)

• Placement of ureteral stent and radiological supervision (50393, 74480)

• Nephrostogram injection (50394)

• Replacement of ureteral stent via ileal conduit (50688).

You should bundle the following procedures into removal/replacement of externally accessible ureteral stent (50387) under NCCI 13.1:

• Percutaneous nephrostomy and radiological supervision (50392, 74475)

• Placement of ureteral stent and radiological supervision (50393, 74480)

• Nephrostogram injection (50394)

• Establishment of nephrostomy tract and radiological supervision (50395, 74485)

• Change of nephrostomy tube (50398)

• Change of ureteral stent via ileal conduit (50688).

 NCCI 13.1 also bundles the following procedures into nephrostomy tube removal under fluoroscopic guidance (50389):

• Placement of ureteral stent (50393)

• Nephrostogram injection (50394)

• Fluoroscopy guidance (77002).

In addition: Removal/replacement of an internal ureteral stent (50382) is bundled into percutaneous nephrostolithotomy (PCNL -- stone fragmentation and extraction via nephrostomy 50080, 50081).
 
Pointer: All of these edits have a modifier indicator of "1," Ferragamo says.

Don't Let 3 Urinary Tract Edits Trip You Up

If, at times, your urologist performs radiological procedures, the most problematic of the new urinary code edits will be when these radiological procedures are also billed with percutaneous urinary tract procedures, such as ureteral stents and nephrostomy.

You may be accustomed to reporting these radiological and surgical code pairs together providing the following:

• different bilateral procedures at the same encounter for patients with right and left drainage tubes

• several therapeutic and radiological procedures on one side during the same encounter

• a diagnostic study (antegrade pyelogram or nephrostogram) before stent or catheter placement.

 Because all of these edits have modifier status "1," you need to evaluate each case individually to determine whether overriding the edit is appropriate.

Example: With NCCI 13.1, you may report 50394-59 (nephrostogram injection -- column 2), along with ureteral stent removal/replacement (50382 or 50387; column 1), only when the documentation supports a medically necessary diagnostic contrast exam prior to the therapeutic procedure (stent replacement).

Don't code the nephrostogram (50394) for a planned routine replacement of a ureteral catheter (50387) because the preliminary imaging is part of the catheter change. However, if the patient presents for a diagnostic contrast exam (50394) and stone removal, code both the nephrostogram (50394 with modifier 59 appended to show that this was a distinct, separate procedure) and the ureteral catheter replacement, as well as the stone removal, 50561 (Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus).

In summary, you should report the following for this example:

• 50561

• 50387-51

• 50394-59.