Urology Coding Alert

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 [...]