Urology Coding Alert

Heads up: Remember you won’t always be paid for the injection agent.

Urologists might perform urethral or bladder injections for a variety of reasons, many of which can be reported with the same code. Read on for the latest advice from Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook, to ensure you complete these procedure claims correctly.

Tip 1: Watch for Multiple Injection Sites

A Urology Coding Alert subscriber asked for help with this coding scenario: Our doctor injected Botox into the bladder wall and then injected two syringes of Durasphere at the 8 o-clock and 4 o-clock positions at the mid-urethra. Do we report separate codes because these were two different locations, or are the injections bundled?

Answer 1: Your provider injected the bladder and the urethra, which are considered to be separate organs. Coding guidelines allow you to report both injection codes in this situation:

• 51715 (Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck) for the injection within the mid-urethra
• 52287 (Cystourethroscopy, with injection[s] for chemodenervation of the bladder) for the Botox injections into the bladder. Attach modifier XS (Separate structure) to 52287 since the bladder is a separate organ from the urethra and therefore, both procedures should be paid.
• One should always check to see if procedures are bundled, and, if they are, if you can possibly unbundle them with a modifier to report both procedures.

Tip 2: Pay Attention to Payment Indicators

A different Urology Coding Alert subscriber had questions about being denied payment for a urethral bulking agent: We submitted a claim to Medicare with 51715 for an endoscopic injection procedure in the ASC and included L8606 for the bulking agent (Macroplastique). Our urologist injected 5cc of Macroplastique, so we listed L8606 on the claim five times. Medicare did not pay for the L8606. This is an expensive medication, and we believe the physician should be compensated for product use. Should we have billed L8606 differently? Should we have included a modifier?

Answer 2: According to CMS coding guidelines, “Contractors shall deny services for HCPCS with payment indicators L1 (Influenza vaccine; pneumococcal vaccine. Packaged item/service; no separate payment made), N1 (Packaged service/item; no separate payment made) or S1 (Service not surgical in nature; and not a radiology service payable under the OPPS, drug/biological, or brachytherapy source. Packaged item/service; no separate payment made).”

Code L8606 (Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies) is assigned an ASC payment indicator of N1. This means CMS considers the product to be a packaged item and does not reimburse for it in addition to the procedure.

Other considerations: Your provider can sometimes receive payment for L8606 or similar HCPCS codes in other circumstances and depending on the associated diagnosis. For example, Medicare and most private insurers cover Macroplastique as a urethral bulking agent for adult female stress urinary incontinence due primarily to intrinsic sphincter deficiency (ISD).

Here’s how: Insurers might have differing guidelines regarding acceptable diagnosis codes for the bulking agent procedure. Your starting points should be N36.42 (Intrinsic sphincter deficiency (ISD)) as the primary diagnosis and N39.3 (Stress incontinence (female) (male)) as the secondary.

Macroplastique, Durasphere, and Tegress are examples of synthetic bulking agents that urologists commonly use for these injections. You will again submit procedure code 51715 and include L8606 for the agent. However, you won’t receive payment for L8606 in an ASC environment, but still need to include the code on your claim to document the injection agent administered.

Take note: In the past, the urologist had the choice of administering either a collagen or synthetic bulking agent. A synthetic agent is your only choice now, as Ferragamo points out that collagen is no longer payable as a bulking agent.