Urology Coding Alert

Urology coders may think they've gotten off easy with the latest CCI edits, but if they don't give the small number of bundles the attention they deserve, they shouldn't be surprised when they start seeing frequent denials for some common urology procedures.

Of the four urology-related bundles included in CCI version 9.1 effective April 1 through July 31 one new bundle stands out as a potential source of problems for urology coders: the bundling of the lower-level E/M code 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) into code CPT 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging). This unusual edit bundles an E/M service into a diagnostic study that appears in the surgical session of CPT, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

The bundling of 99211 into 51798 definitely has the potential of affecting claims for office visits. Ferragamo offers this example of how the new bundle will affect coding: When a nurse or medical technician documents performing a hand-held Doppler device bladder scan in the urologist's office while the urologist is in the office suite and has had a face-to-face medical encounter with the patient that included an evaluation and exam separate and distinct from the bladder scan, technically you will now have to code the scenario 51798, 99211-59. However, most carriers will not recognize modifier -59 (Distinct procedural service) when appended to an E/M service, he adds. "Consequently, in this scenario, the 99211 appears to be a nonreimbursable service an appeal may be your only chance for payment."

The new bundling of bladder irrigation code 51700* (Bladder irrigation, simple, lavage and/or instillation) into cystoscopy code 52000 (Cystourethroscopy [separate procedure]) is another new edit, but one that is more likely to affect claims for surgical procedures.

"During the black-box editing phase, when code bundles were not made public, code 51700 had previously been bundled into code 52000," Ferragamo says, "and now they've bundled them again." It seems as though the edits are trying to reinforce the idea that you should not separately report bladder irrigation when you are using the irrigation to assist in visualization of the bladder during a cystoscopic examination, he says. But, if the irrigation procedure comprises a significant portion of an operative encounter, i.e., if one hour of irrigating clots is followed by a 10-minute cystoscopy, use of code 52001 (Cystourethroscopy with irrigation and evacuation of multiple obstructing clots) would seem most appropriate.

Both the 99211/51798 bundle and the 51700/52000 bundle are assigned a modifier indicator of "1," which means under certain clinical circumstances the codes can be reported separately by appending modifier -59 to the component code, the code that is considered "included in" or has been "bundled into" another procedure code.

And several radiology codes, including 76775 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], B-scan and/or real time with image documentation; limited), 76857 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [e.g., for follicles]), 76870 (Ultrasound, scrotum and contents), 76872 (Echography, transrectal) and 76873 ( prostate volume study for brachytherapy treatment planning [separate procedure]), now include minor surgical procedure codes 51701 and 51702. "So now when a bladder sonography (76775) is performed and the urologist decides to drain the bladder with a catheter, for example, you will need to append modifier -59 to the catheter code (51701 or 51702) to receive separate payment," Ferragamo says.

Another edit that will affect surgical coding is the bundling of code 50780 (Ureteroneocystostomy; anastomosis of single ureter to bladder) into renal transplantation codes 50365 (Renal allotransplantation, implantation of graft; with recipient nephrectomy) and 50380 (Renal autotransplantation, reimplantation of kidney).