Urology Coding Alert

Physicians who dont bill for a bilateral procedure when it is performed as such are missing out on money. In the case of 50590 (lithotripsy, extracorporeal shock wave), they are missing out on major money about $1000. Just because most doctors dont do bilateral lithotripsies, that doesnt mean it never happens. And when it does, you need to know how to bill for it.

If you do a bilateral extracorporeal shock wave lithotripsy (ESWL), you would bill 50590-50, according to coding experts. The 50590 code accepts modifier -50 (bilateral procedure), notes Michael Ferragamo, MD, who practices with Ferragamo, Bruno, Efros, PC of Hempstead, N.Y. Its rather uncommon to do both at the same time, he admits. Most urologists wouldnt do it at the same session because if both stones came out, there could be an obstruction, the urologist notes. (The ESWL pulverizes the stone, and the fragments are then passed through the ureter. Sometimes a fragment might obstruct a ureter. If an ESWL is done bilaterally, then there is a chance that both ureters could be obstructed, which is life-threatening.) Normally, you would do one lithotripsy for one kidney, with a stent up the other side.

Kathy West, biller for Shore Urology of Long Branch, N.J., notes that if 50590 is billed with the -50 modifier, you will be paid 100 percent for the first procedure and 50 percent for the second.

Using Modifiers for Subsequent ESWLS

A more common situation is multiple ESWLs, which are done subsequent to each other, rather than at the same time. You can do as many sessions as you want, says Ferragamo. But most physicians will move onto another treatment after the second or third session. If the ESWL is not breaking up the stone or stones, the urologist may recommend a different therapy.

If the second ESWL is within the global period of the first, you are going to have to use a modifier. Here are the different modifiers you should use, depending on the situation:

Modifier -58 (staged or related procedure or service by the same physician during the postoperative period). If the second ESWL is for the same stone and done within the postoperative period, you should use modifier -58 to indicate that the second is a planned or staged procedure. This is why, before I do an ESWL on a big stone, I say in my dictation that this may be the first in a staged procedure, says Ferragamo. I know ahead of time that I may not get it in one session. But its not just enough to know it you have to put it in the documentation. After all, a staged or planned procedure cant be termed that after the fact, just because you decide to do a second ESWL. If you are audited, you need to be able to show that you did in fact plan to do another at the time that you did the first. If you put it into your dictation before the first ESWL, it will get into your documentation. That gives you a way out to use modifier -58 the next time, says Ferragamo.

Be very precise in documentation. If you think you are going to have to do another ESWL, say so. Otherwise, the modifier -58 will not hold up in an audit. Likewise, you should not write that you may need to do another ESWL if you dont. An audit of charts showing that every initial ESWL has documentation saying that another might be necessary would not reflect well on you. If you have to do a subsequent ESWL within the global period and you did not indicate in the chart that this was planned, you must bill it with a modifier -78 (return to the operating room for a related procedure during the postoperative period), which will pay you only part of the fee for the ESWL, rather than the 100 percent that modifier -58 will pay.

Modifier -79 (unrelated procedure or service by the same physician during the postoperative period).
If the second ESWL is for a different stone in the same kidney and done within the postoperative period of the first ESWL, you should use modifier -79 to indicate an unrelated procedure. Lets say the patient comes in for another stone in the same kidney two weeks after the first ESWL, says West. This is unrelated because its a separate stone.

Modifier -79 plus -RT or -LT (left side or right side). If the second ESWL is for the other kidney and is done within the postoperative period of the first ESWL, you should use the -RT and -LT modifiers to indicate that it is a different kidney. However, you may well need to submit operative notes with your claim to clearly explain what you did.

None of the above modifiers should affect payment you should be paid 100 percent for the subsequent ESWLs.

A note about multiple stones: If there are several stones in one kidney, you cannot charge 50590 more than once for that session. The -50 modifier is used only when both kidneys have stones that require ESWL treatment.