Urology Coding Alert

Question: We recently billed CPT 52601 (Transurethral electrosurgical resection of prostate ...) and 52318-59-51 (Multiple procedures) and we received only 9 percent of the fee for the litholapaxy. Did we misuse the two modifiers? Why did we get paid so much less when we billed them together?

North Dakota Subscriber

Answer: Technically, modifier -59 (Distinct procedural service) is not required for 52334 because this code is no longer bundled into 52318 but this may not be the source of your low reimbursement.

The reduction you note in the fee for 52318 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large [over 2.5 cm]) is in part a result of the multiple endoscopic procedures reduction. When two or more endoscopic services are billed at the same time, Medicare accounts for the fact that these endoscopic services use the same surgical approach, endoscopy, with a fee reduction. Medicare reduces the allowed payment for all secondary and tertiary service by 50 percent because the differences in their surgical approaches are difficult to quantify. However, for endoscopic services, Medicare can quantify the surgical approach and has assigned a "base code" to represent the endoscopic surgical approach.

For example, CPTcodes 52234 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 to 2.0 cm]) and 52318 have the same base code: 52000 (Cystourethroscopy). Therefore, Medicare deducts the relative value units for this base code from your secondary code, 52234, before it incurs the 50 percent multiple-procedures reduction; hence, the low payment for 52234.