Urology Coding Alert

Question:My urologist documented a surgery as “robotic assisted bladder diverticulectomy.” I didn’t find a direct CPT® code for this service so I used the unlisted CPT® code 51999(Unlisted laparoscopy procedure, bladder). But the insurance is denying 51999. We even appealed two times with documents, but they still denied the claim. Can we use 51520 for reimbursement purpose?

Idaho Subscriber

Answer:`At times some payers will not initially recognize unlisted CPT® codes and hence will not reimburse for these services.

Remember when using unlisted codes for procedures that do not have specific CPT® codes, in addition to the CMS-1500 claim form or the electronic equivalent submission, you should also submit to the payer a detailed operative report and a covering letter describing in laymen’s terms the operation performed, the absence of a specific CPT® code for the procedure, the expertise and work required, postoperative recovery time, and any complication that could arise.

In this letter one should also bench mark (identify) another CPT® code from the recent CPT® manual that would be similar in work and time to the unlisted procedure billed. In your case bench mark your unlisted code to the open code 51525 (Cystotomy; for excision of bladder diverticulum, single or multiple [separate procedure]). Indicate the increased knowledge and technology required for a robotic/laparoscopic approach and state your fee at least 50 percent more than the fee one would bill for the bench marked open procedure.

If all of this documentation and clinical information fails in your quest for reimbursement, speak with the payer’s medical director for instructions on billing for these services. Unless you receive written instructions from the insurance company to use an open code for billing a robotic procedure, do not substitute an open procedure coding for an unlisted specific robotic or laparoscopic procedure.