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Urology Coding Alert

News Brief:

Controversy Surrounds CCI Changes to 52001

Published on Fri Feb 01, 2002

Version 8.0 of the Correct Coding Initiative (CCI) contains several changes for urology. The most controversial involves new code 52001 (Cystourethroscopy with irrigation and evacuation of clots), which includes 52000 (Cystourethroscopy [separate procedure]) and 51700 (Bladder irrigation, simple, lavage and/or instillation).

Unbundling
 
Unbundling of 52001 with 52000 or 51700 is allowed under certain circumstances. For example, a urologist performs cystoscopy and irrigation of blood clots in the morning. Report 52001. Later that day, the urologist irrigates the bladder again. Bill 51700-59 (Distinct procedural service), indicating that the second irrigation was performed on the same day but at a different encounter than the first.

Fee Schedule
 
New code 52001 pays more than 52000 when performed in a hospital, but much less than 52000 when performed in the office because Medicare has not yet given 52001 a place-of-service differential. The relatively low fee for 52001 done in the office has prompted urologists to propose coding for in-office clot evacuation as though 52001 is nonexistent. They feel it is fair to bill 52000 and 51700 in the office (these codes are not bundled).

The Urologists Viewpoint
 
Code 52001 (nonfacility and facility relative value units [RVUs] 3.67) will probably be performed in a hospital or ambulatory surgical center, says Michael A. Ferragamo, MD, professor of urology at the State University of New York, Stony Brook. A large-diameter cystoscopy sheath is typically inserted into the bladder, and clots are evacuated through this sheath using an Ellik or piston syringe evacuator. After irrigation, the cystoscopic telescope is placed through the same sheath, and a cystoscopic viewing of the bladder is accomplished. For the above work, report 52001 on one line for the urological work performed. In a facility setting, 52001 pays much more than 52000 (3.67 compared to 2.82 RVUs).
 
In contrast, Ferragamo says, in the modern urology office, cystoscopy is performed with a small-diameter flexible cystoscope. Because of its small size the irrigation portal is inadequate for evaluation of blood clots. On the rare occasion when it becomes necessary to irrigate clots from the bladder in an office setting, a large-diameter catheter is inserted for irrigation, and after its removal cystoscopy is performed with the introduction of the flexible scope. For the above in an office setting, bill 52000 (nonfacility RVUs 5.58), rather than 52001 (facility and nonfacility RVUs 3.67). If irrigation prior to cystoscopy is significant, report 52000 and 51700-51 (Multiple procedures) to delineate the separate endoscopic manipulations performed.
 
One must understand the differences noted when performing and coding these procedures, Ferragamo says. For example, if a urologist performs a cystoscopy (52000) and a urethral dilation (53600-53665), the correct code is 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female), which pays more than the highest-paying individual code. Another example, Ferragamo says, is a radical cystectomy (51570-51575) and an ileal conduit (50820, Ureteroileal conduit [ileal bladder], including intestine anastomosis [Bricker operation]). When performed together, the correct code range is 51590-51595, each of which pays more than either component alone, although not as much as both when added together. Code 52001, however, when performed in the office, pays less than the highest component of the two-code combination 52000 and 51700.
 
 In the future, hopefully 52001 will also receive a place-of-service differential to increase its value over cystoscopy alone when performed in the office, Ferragamo says.

The Coders Viewpoint
 
Do not succumb to the temptation to bill 52000 and 51700 instead of 52001 to get paid more when irrigating out clots via cystoscopy in the office, urges Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding and compliance consultancy based in Denver. Before 52001 existed, this was the recommended code combination. But there is a code for clot evacuation now, Page says. Its not correct coding to use 52000, or to use 52000 with 51700.
 
If a urologist misuses 52001 by billing 52000 with 51700, there is a good chance he or she could be cited for abusive coding practices if the documentation is reviewed, Page says. Some reviewers may even consider this to be fraud because the service is coded for reimbursement purposes only. The CPT descriptor in 52001 makes no mention of the site of the sheath used. Separate the CPT issues from the RVU issues.

Other Changes
 
New code 53431 (Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence [e.g., Tenago, Leadbetter procedure]) includes 51990 (Laparoscopy, surgical; urethral suspension for stress incontinence), 51992 ( sling operation for stress incontinence [e.g., fascia or synthetic]), 53000 (Urethrotomy or urethrostomy, external [separate procedure]; pendulous urethra), 53020 (Meatotomy, cutting of meatus [separate procedure]; except infant), 53025 ( infant), 53080 (Drainage of perineal urinary extravasation; uncomplicated [separate procedure]), 53502 (Urethrorrhaphy, suture of urethral wound or injury, female), 53505 (Urethrorrhaphy, suture of urethral wound or injury; penile), 53510 ( perineal), 53515 ( prostatomembranous), 53520 (Closure of urethrostomy or urethrocutaneous fistula, male [separate procedure]), and add-on code 69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]). No unbundling is ever allowed with 53000, 53020 and 53025 due to the CPT separate-procedure definition. No unbundling is allowed with the operating microscope code 69990.
 
Codes 53440 (Operation for correction of male urinary incontinence, with or without introduction of prosthesis), 53445 (Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff), and 53447 (Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session) now include 53444 (Insertion of tandem cuff [dual cuff]); unbundling is allowed.
 
Code 53447 includes 53444, 53445 and 53446 (Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff). Unbundling is allowed with modifier -59 (Distinct procedural service).
 
Code 53448 (Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and debridement of infected tissue) now includes 11040 (Debridement; skin, partial thickness), 11041 ( skin, full thickness), 11042 ( skin, and subcutaneous tissue), and 11043 ( skin, subcutaneous tissue, and muscle), as well as 53444, 53445 and 53446. Unbundling is allowed with modifier -59.
 
Codes 54150 (Circumcision, using clamp or other device; newborn), 54152 ( except newborn), 54160 (Circumcision, surgical excision other than clamp, device or dorsal slit; newborn), 54161 ( except newborn), new code 54162 (Lysis or excision of penile post-circumcision adhesions), and new code 54163 (Repair incomplete circumcision) all include new code 54164 (Frenulotomy of penis). Unbundling is allowed with modifier -59.
 
Code 54405 (Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir) now includes new code 54408 (Repair of component[s] of a multi-component, inflatable penile prosthesis); no unbundling is allowed. New code 54406 (Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis) now includes 54405; no unbundling is allowed. Codes 54406 and 54408 also include 69990; no unbundling is allowed.
 
New code 54410 (Removal and replacement of all component[s] of a multi-component, inflatable penile prosthesis at the same operative session) now includes 54405, 54406 and 69990. Unbundling is allowed with 54406, but not with 54405 or 69990.
 
New code 54411 (Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue) now includes 11040, 11041, 11042 and 11043; unbundling is allowed with modifier -59.
 
New code 54415 (Removal of non-inflatable [semi-rigid] or inflatable [self-contained] penile prosthesis, without replacement of prosthesis) includes 54400 (Insertion of penile prosthesis; non-inflatable [semi-rigid]), 54401 ( inflatable [self-contained]), and 69990. No unbundling is allowed.
 
New code 54416 (Removal and replacement of non-inflatable [semi-rigid] or inflatable [self-contained] penile prosthesis at the same operative session) includes 54400, 54401, 54405, 54415 and 69990. Unbundling is allowed only with 54415.
 
New code 54417 (Removal and replacement of non-inflatable [semi-rigid] or inflatable [self-contained] penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue) includes 11040, 11041, 11042 and 11043. Unbund-ling is allowed with modifier -59.
 
Code 54512 (Excision of extraparenchymal lesion of testis) includes 54500 (Biopsy of testis, needle [separate procedure]), 54505 (Biopsy of testis, incisional [separate procedure]), 54660 (Insertion of testicular prosthesis [separate procedure]), 54700 (Incision and drainage of epididymis, testis and/or scrotal space [e.g., abscess or hematoma]) and 69900; unbundling is allowed with all except 69900, with modifier -59.
 
Codes 54520 (Orchiectomy, simple [including subcapsular], with or without testicular prosthesis, scrotal or inguinal approach), 54640 (Orchiopexy, inguinal approach, with or without hernia repair), and 54650 (Orchiopexy, abdominal approach, for intra-abdominal testis [e.g., Fowler-Stephens]) now include 54512; unbundling is allowed with modifier -59.

Modifier -59
 
Unbundling with modifier -59 indicates that a bundled procedure is billable. For example, a urologist performs 54417 in the morning and 11040 later that day. Both are payable services using modifier -59 on the second procedure.
 
In another example, a urologist performs 54416 in the morning and later that day performs 54415. Both are payable with modifier -59 on the second procedure.
 
In a different kind of example, a bundled procedure is performed the same day, but on another part of the body. A urologist performs a left orchiectomy (54520) with an excision of an extraparenchymal lesion of the right testicle (54512) with modifier -59 appended. Both are billable and payable. Use modifier -LT (Left side) on 54520, and modifiers -59 and -RT (Right side) on 54512.
 
In another example, a urologist performs 54512 on the right testicle, and a biopsy of the left testicle (54500-59 or 54505-59). Both are billable and payable. Append modifiers -LT and -RT.

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