Urology Coding Alert

Multiple procedures do not necessarily mean multiple payments from carriers, particularly for related endoscopies performed on the same day or session. But you dont have to give up on reimbursement either. By using modifiers correctly and adjusting, urologists can maximize their billing for these multiple claims.

There is a lot of confusion about whether to use modifier -59 (distinct procedural service), modifier -51 (multiple procedures), or no modifier at all with multiple endoscopies. If the payer is not Medicare, but commercial, you need to find out how it wants you to bill these procedures. Although you should not use modifier -51 when billing Medicare for multiple procedures within the same coding family, commercial payers may have different policies.

For commercials we bill the regular fee without making any adjustments and without any modifiers, says Jackie Shovan, CPC, financial counselor with the division of urology at the University of Utah in Salt Lake City. We know that the payers will always subtract the base code.

Fee Adjustments

For example, the base code for cystoscopy is 52000 (cystourethroscopy [separate procedure]). But many times this code will not be filed at all. Instead, you might file any one of the other procedure codes that encompasses a cystoscopy. Do not append the modifier -51 in these casesthat will reduce your payment by half. In some specific circumstances, modifier -59 is appropriate when billing multiple endoscopic procedures (different sites, for example).

To avoid inappropriate bundling and to ensure proper reimbursement urologists should reduce the fee for the base procedure if is is included in more than one of the procedures they are billing. Even with procedures that are not bundled, you need to reduce the fee for the base procedure. If the urologist performs 52260 (cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction [spinal] anesthesia) and 52007 (cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis), it is not the same as 52204 (cystourethroscopy, with biopsy), which is a regular biopsy of the bladder. If youre already in there with the scope and you do a biopsy, thats just part of the code, says Susan Callaway-Stradley, CPC, an independent coding consultant based in North Augusta, S.C. But 52007 is a particular type of biopsya brush biopsyand its for the ureter and renal pelvis, not just the bladder, she says. Urologists should code these two procedures as follows:

You need to make sure you are not billing twice for the base codethe cystoscopy (52000). But this isnt done via a modifier. Medicare will do it for you by adjusting your fee. Do not adjust the fee ahead of time. If youre a participating Medicare provider, that will happen automatically. But expect reimbursements to be reduced by the base code. If Medicare pays $216 for 52260 and $203 for 52007, and $100 for base code 52000, expect Medicare to reduce the 52207 by $100. Your claim would look like this:

52260: $216
52007: $203
Total: $419

But you would actually receive only $319, because Medicare would subtract the $100 from the $203. (See box on page 11 for Medicares policy on multiple endoscopies.)

Modifier -51 for Unrelated Procedures

Modifier -51 is being used too often by urology practices for multiple endoscopies, but it only reduces the payment. First of all, modifier -51 is for multiple surgeries that are not components of or incidental to a primary procedure. That means you do not use modifier -51 for multiple endoscopies that are in the same family (e.g., 52000 is the base code for a cystoscopy, and all other codes that include a cystoscopy are in that family).

When there are multiple surgeries, the highest-valued procedure pays at 100 percent of the Medicare fee schedule, and the second highest-valued procedure at 50 percent. Modifier -51 is appended on the second procedure.

Modifier -59 to Break Bundles

Modifier -59 may be needed for billing multiple endoscopic procedures when you are trying to indicate that a distinct procedural service was performed. This procedure must be distinct or independent from other services performed on the same day.

First, you need to make sure that codes arent bundled. For example, if the urologist performs 52005 (cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service), 52204 and 52260, Medicare will pay for the 52260 only, says Stella Natarova, MS, CPC, CCS-P, director of compliance and reimbursement for Adult and Pediatric Urology Group of Maryland in Baltimore. The biopsy is almost always included in 52260, she explains. And the original cystoscopy can never be billed with 52260. The Correct Coding Initiative (CCI) has a 0 next to the 52005, she says. That means theres no way you can bill for the 52205. There is a 1 next to the 52204 in the CCI, which means that you can bill for both the 52260 and the 52204 under specific circumstances, says Natarova.

Modifier -59 is to be used when there are procedures that are not reported together normally (i.e., bundled), but which under certain circumstances are appropriate to bill together. According to CPT, these circumstances include: different sessions or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries).
This might happen with 52260 and 52204, says Natarova. The rationale for the modifier -59 and billing for the cystoscopy twice could not be a separate site because the bladder is only one area, she notes. But the urologist occasionally would do the two procedures by dilating the bladder with the aid of the cystoscope, then removing the scope and letting the bladder remain full for 10 to 15 minutes. He would remove the solution and insert the cystoscope a second time to perform the biopsy. You would file the claim 52260 on the first line and 52204-59 on the second line. Natarova stresses that this occurs rarely.

Callaway-Stradley is not convinced that Medicare would agree with the need to reinsert the cystoscope. If audited, you must have met the listed criteria to avoid trouble, she says. The biopsy is usually incidental to the major procedure of dilation of the bladder, and therefore usually would not be payable according to the CCI guidelines, explains Callaway-Stradley. It would only be under special circumstances, Natarova says, that you could use the modifier -59.

Medicares Policy on Multiple Endoscopies When multiple procedures are performed through the same endoscope, payment will be made for the highest valued endoscopy (100 percent of the allowance) plus the difference between the next highest and the base endoscopy, and so forth when more than two related endoscopies are reported. Apply the following rules where endoscopies are performed on the same day as unrelated endoscopies or other surgical procedures: - Two unrelated endoscopies: apply the usual multiple surgery rules. - Two sets of unrelated endoscopies: apply the special endoscopy rules to each series and then apply the multiple surgery rules, and consider the total payment for each set of endoscopies as one service. - Two related endoscopies and a third, unrelated procedure: apply the special endoscopic rules to the related endoscopies, and then apply the multiple surgery rules. Consider the total payment for the related endoscopies as one service and the unrelated endoscopy as another service. Note: The Medicare Fee Schedule Database identifies those procedures subject to the endoscopy rules and whether they are related endoscopies.