Urology Coding Alert

Question: A patient came into the office complaining of impotence. We billed J2440 and 54235-51. Medicare is not paying us for CPT 54235. Why not?

Oregon Subscriber

Answer: Since patients usually perform penile injections themselves at home, you're usually only allowed to bill 54235 (Injection of corpora cavernosa with pharmacologic agent[s]; multiple procedures) once in each beneficiary's lifetime. (Check with your own payer for its policy.) Usually, that procedure is to calculate the effects of the drug on the patient or to titrate the correct dosage. You can also report the medicine using the proper J code, in this case J2440 (Injection, papaverine HCl, up to 60 mg) - but be sure the urologist isn't using a free sample.

Once the dosage and drug have been established, if the patient returns to learn how to inject the drug himself, and your nurse or medical technician instructs him, you can report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician).

For most carriers, an initial injection, 54235, is a payable service along with an E/M service with modifier   -25, if the latter represents a significant and separately identifiable service over and above the injection therapy. Most likely, this case represents a second injection.