Urology Coding Alert

Hint: Focus on the results, not the type of laser.

When your urologist documents that he performed a laser prostatectomy to treat a patients benign prostatic hyperplasia (BPH), you wont be sure youre reporting the correct code unless you dig deeper -- and reporting the wrong code could cost your practice reimbursement dollars and set you up for payer audits. Learn what key words to look for with these expert tips on codes 52647-52649.

Avoid Coding Based on Technique Alone

You may think that you should base your laser prostatectomy coding on the type of laser your urologist uses during the procedure. Thats not the case, says Michael A.Ferragamo, MD, FACS, clinical assistant professor of urology at the State Universityof New York in Stony Brook, New York.

Reality: You should base your code choice on the laser energy effect on the prostatic adenoma -- coagulation or vaporization -- and on the technique used -- ablation, enucleation, or a combination of both. Youll choose between three codes:

" 52647 -- Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed)

" 52648 -- Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed)

" 52649 -- Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed).

The proper CPT code choice is based upon the surgical technique applied rather than the laser and laser wavelength used, explains Jonathan Rubenstein, MD, director of coding and physician compliance for Chesapeake Urology Associates in Baltimore.

The CPT terminology focuses specifically on the results of the laser treatment rather than the laser itself. Therefore, your coding should reflect this distinction as well. If your urologist does not provide the information you need to choose a code, you need to ask him to amend the note prior to your coding. Having a great line of communication with your doctors is vital, says Vickie Rhodes, CPC, billing and coding specialist for Greenwood Urological in South Carolina.

Example: Although urologists use the Holmium laser to vaporize (52648) the tissue of the prostate, they often also use it in the technique of enucleating the prostatic adenoma (52649), a procedure that requires more work than either vaporization or coagulation. You cannot just find in the urologists note that he used the Holmium laser and pick your code. You also need to determine what technique he used in treating the prostatic obstruction. Choosing the proper code certainly depends on how the doctor uses the laser to perform the surgery, Rhodes confirms. If the doctor says he vaporized the prostate or the prostate was vaporized, I know to use 52648.

Get to Know the Code Differences

Clinical rationale: Urologists are choosing laser treatments of the prostate rather than transurethral resections of the prostate (TURP) more often. Lasers vaporize a layer of the surface of the prostate, and cause blood to clot. For some patients, there will be less bleeding with a laser than with a traditional TURP procedure, according to the prostate surgery medical policy from Blue Cross Blue Shield of Massachusetts (www.bluecrossma.com/common/en_US/medical_policies/384 Prostate Surgery prn.pdf). In treating prostatic obstruction the urologist may choose from different laser treatments.

CPT defines 52647 as laser coagulation of the prostate. This code is intended to describe laser procedures that primarily heat the prostate and require sloughing for the treatment to be complete, according to CPT Assistant (Nov. 2006).

In contrast, 52648 describes laser vaporization of the prostate: & vaporization is usually accomplished by moving a laser tip across the surface of the prostate, causing immediate vaporization of tissue and an end result that looks like a cavity (similar to the effect of a Transurethral Resection of the Prostate), says CPT Assistant.

Youll use 52648 when your urologist uses the GreenLight laser (also known as photoselective vaporization of the prostate, PVP) or the Holmium laser to vaporize the prostate. Note that in choosing the proper CPT code you no longer need to determine whether the urologist used a contact or non-contact technique.

Vaporization Doesnt Always Mean 52648

Important: CPT specifies that you should not report 52648 separately from 52647 for a small amount of vaporization along with the coagulation. You should use 52647 alone even if your urologist makes an incision or does a small amount of vaporization in combination with the coagulation.

Note that laser coagulation of the prostate, also known as interstitial laser coagulation (ILC) technology -- reported with 52647 -- has recently been removed from the marketplace, and most laser treatments performed today are with the GreenLight or Holmium laser.

Bottom line: Coders should look for the technique employed and the laser used to help them choose the proper code, Rubenstein says. In my practice, the coagulation code (52647) was reserved for the Indigo laser coagulation, and we no longer perform this technique. Vaporization (52648) is likely the most commonly used technique these days and can be performed with a variety of lasers, such as the Holmium and KTP laser, such as the GreenLight procedure. It should be obvious in the operative note if enucleation (52649) was performed, based upon the surgeons dictation, they should use the word enucleation itself, he adds.

In January 2008, CPT introduced 52649, finally providing you with a long-awaited code for the laser enucleation of the prostate, commonly known as HoLEP (Holmium laser enucleation of the prostate).

Sample scenario: Code 52649 is for the particular technique wherein the prostatic adenoma is enucleated as a whole lobe, usually with the Holmium laser, and then the enucleated adenoma is washed into the bladder. If your urologist uses this particular technique, the prostatic adenoma must then be morcellated into smaller fragments that may easily be irrigated from the bladder. Youll use 52649 for this procedure. If the prostate is specifically vaporized without enucleation or morcellation, bill 52648,Ferragamo says.

Beware of Bundled Procedures

As the code descriptors indicate, you should not separately report vasectomy, meatotomy, dilation, urethrotomy, or resection of the prostate along with codes 52647-52649. Urologists occasionally perform these procedures prior to the laser treatment. The procedures are bundled into the laser codes and represent integral parts of the over-all procedure, Ferragamo explains. Do not separately bill for these procedures.

Similarly, one cannot bill a complex catheter placement or other urethral access procedures because payers consider these procedures inherent to gaining access to perform the procedure, Rubenstein cautions.

The Correct Coding Initiative (CCI) also bundles the laser prostatectomy codes with many other prostatic procedures for benign prostatic hyperplasia (BPH),including 52450 (Transurethral incision of prostate) and TURP codes, Rhodes points out. Be sure to check the CCI edits and your payers specific bundling before billing 52647-52649 with other procedure codes.

You should always check your CCI edits for bundling guidelines, Rhodes says. There are a lot of urology codes that are bundled and billing them correctly is essential to your reimbursement.