Advanced Search

Urology Coding Alert

Optimize Reimbursement:

Know When to Use Modifier -50 on Cystourethroscopies

Published on Sun Jul 01, 2001

Urology coders should distinguish between CPT and Medicare guidelines when appending modifier -50 (bilateral procedure) to a cystourethroscopic procedure (52000-52355) for proper reimbursement. The code descriptors for cystourethroscopic procedures do not clearly indicate if the -50 modifier is appropriate because there is one bladder, but there are two ureters. When the descriptor includes language such as "... with ureteral catheterization," you can perform it twice and therefore can bill it with modifier -50 under CPT rules. But CPT rules are at odds with Medicare rules for some cystourethroscopy procedures.
 
No Modifier -50: Medicare and CPT Agree
 
On a straight cystourethroscopy, Medicare and CPT agree: Do not use modifier -50. Cystourethroscopy literally means "looking into the bladder." Therefore, it is not appropriate to append modifier -50 to a cystourethroscopy code that has no other procedure included, such as a ureteroscopic procedure, because urologists can look into only one bladder. Both CPT and Medicare rules agree that 52000 (cystourethroscopy [separate procedure]) cannot take modifier -50 because it cannot be performed bilaterally. 

Whether you use the phrase "inherently bilateral," as CPT does, or simply view a cystourethroscopy as medically impossible to do bilaterally, the end result is the same: You cannot append modifier -50 to 52000 or to many other procedures. 

In fact, any cystourethroscopy code referring only to the bladder cannot take modifier -50, under either Medicare or CPT, says Jan Brunetti, CPC, coder for Urology Associates, a four-urologist practice in Newport, R.I. "That's because you're there anyway," she says. "Don't try to bill bilaterally just because something is done on both sides of the bladder. That would really be stretching it."

Other cystourethroscopy codes that neither Medicare nor CPT allows to be billed with modifier -50 include 52010, 52204-52285 and 52305-52318. These codes cannot be billed with modifier -50 because they are "inherently bilateral," according to CPT. In other words, when you perform a procedure such as 52214 (cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands), the entire area is included. "There may be several bleeding points in the trigone," says Michael A. Ferragamo, MD, assistant clinical professor of urology at the State University of New York, Stonybrook. "But still you can only bill 52214. You get no extra credit for fulgurating on both sides of the trigone."

In another example, the urologist removes a foreign body from the bladder. Report 52310 (cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) for this procedure. Even if there are two foreign bodies, do not append modifier -50, under either CPT or Medicare rules. Although removing two ureteral stents seems to be a clear case for modifier -50, neither Medicare nor CPT rules allow it on 52310.

Tip: Ferragamo recommends coding 52315 (... complicated) for two stent removals. Likewise, use 52315 if you must remove multiple foreign bodies, as when seeds following brachytherapy are misplaced and end up in the bladder, or if you must remove multiple stones from the bladder.

CPT and Medicare Disagree

Certain procedures are usually performed unilaterally, but when they are done bilaterally, it is appropriate to bill them with modifier -50.

For example, 52005 (cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) refers to "with ureteral catheterization," which implies that there is only one ureteral catheterization, according to the May 2001 issue of CPT Assistant. So CPT says you can bill 52005 with modifier -50.

Medicare disagrees with CPT on 52005. Medicare has already included the value for both catheterizations in one fee. So when billing Medicare, do not code a retrograde pyelogram with modifier -50. For a private payer, append modifier -50 until you know what the payer wants you to do. Many union insurance plans and some other private payers will pay for bilateral catheter insertion, and CPT, as noted, approves. When you perform 52005 bilaterally, you can bill 52005-50 to a private payer.

Following CPT's logic regarding 52005, one could also say that the ureteral stent in 52310 (see example above) is singular, and therefore that code could appropriately be billed with modifier -50. However, neither CPT nor Medicare allows that.

Other procedures that CPT says you can bill with modifier -50 are 52007 and 52320-52355. Medicare, however, allows modifier -50 only for 52007, 52320, 52325, 52330-52343, 52353 and 52354. Medicare does not allow modifier -50 to be used with 52005, 52327, 52345-52352 and 52355.

Modifier -50 OK: Medicare and CPT Agree

Medicare and CPT agree that modifier -50 can be appended to some codes, such as 52330 and 52332. For example, a patient has a stone in the left ureter and in the right ureter. The urologist manipulates the stones back into the kidney on each side, then places stents in each ureter to keep the stones from coming out. Use 52330 (cystourethroscopy [including ureteral catheterization]; with manipulation, without removal of ureteral calculus) with modifier -50 appended to show that the urologist performed the stone manipulation on both sides.

Also, use 52332 (cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) for placing both stents, with modifier -50 appended to show that the physician performed the same procedure for each side. Per the Correct Coding Initiative edits, report modifier -59 (distinct procedural service) as well. Modifier -51 could be used in the tertiary position if the billing software accepts multiple modifiers. Since most payers process multiple surgeries automatically, modifier -51 usually isn't required.

But the above scenario is unusual, Brunetti says, because patients rarely have stones in both ureters.

In another example, a urologist treats bilateral ureteral strictures at the same time. Report 52344-50 (cystoureth-roscopy with ureteroscopy; with treatment of ureteral stricture [e.g., balloon dilation, laser, electrocautery, and incision) because both ureters are involved. If a urologist biopsies bilateral ureteral tumors, bill 52354-50 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of lesion).  

Unilateral or Bilateral in Descriptor: No Modifier -50

When a code descriptor explicitly states "unilateral or bilateral" as in 52290 (cystourethroscopy; with ureteral meatotomy, unilateral or bilateral), 52300 (cystoureth-roscopy; with resection or fulguration of orthotopic ureterocele[s], unilateral or bilateral) or 52301 (cystourethroscopy; with resection or fulguration of ectopic ureterocele[s], unilateral or bilateral), it is never appropriate to use modifier -50.

Other Articles in this issue of

Urology Coding Alert

View All