Urology Coding Alert

Using 599.82 for SUI implants solves your 51715 woes - but coding for supplies is trickier

Reporting the wrong diagnosis code for the urologist's use of implants to treat stress incontinence could lead to denials - but that's nothing compared to the fraud accusations you could face if you make mistakes when reporting supplies.

When a urologist performs an implant procedure for sphincter deficiency, you should report 51715 (Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck). If the urologist performs this procedure outside the hospital in the urologist's office, you should also report L8603 (Injectable bulking agent, collagen implant, urinary tract, 2.5-ml syringe, includes shipping and necessary supplies) to your local carrier - not your DMERC - for supplies.

Because treatment typically requires more than one syringe, be sure to indicate the appropriate number of syringes used, using units on your CMS-1500 form, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 21-urologist practice in Indianapolis. Indicate the implant material used, the amount implanted and the price paid in box 19 of the CMS-1500 form (or the corresponding field in the electronic form).

Warning: Be aware that Medicare typically only covers "up to five separate collagen implant treatments in patients with intrinsic sphincter deficiency, who have passed a collagen sensitivity test," according to a note in the HCPCS Level II manual. And if you exceed that frequency limit, you could find yourself in hot water with the feds.

Collagen implants require a preoperative skin test for collagen sensitivity, and reporting this test can turn into another federal hot spot if you're not careful. You can report the test separately with 95028 (Intracutaneous [intradermal] tests with allergenic extracts, delayed type reaction, including reading, specify number of tests). 

Protect yourself: Be aware, however, that the vendor usually provides the kits associated with these procedures for free, says Tracy Brookes, office manager for Yakima Urology Associates in Yakima, Wash. If that's the case, you should not report those materials separately.

Many carriers have local coverage determinations (LCDs) that spell out their reimbursement policies for this procedure, so check with your local Medicare carrier before reporting 95028.

ICD-9 solution: Link the skin test and implant procedures to ICD-9 Code 599.82 (Intrinsic [urethral] sphincter deficiency [ISD]) as the primary diagnosis. "Many carriers will pay for this procedure only when this diagnosis (599.82) is used," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York. "Also, many carriers will require the performance of an abdominal or Valsalva leak point pressure determination (51772, Urethral pressure profile studies [UPP] [urethral closure pressure profile], any technique) as well as other urodynamic studies." Use 625.6 (Stress incontinence, female) as a secondary diagnosis, Ferragamo says.