Urology Coding Alert

Question: One of my doctors performed a sling (CPT 57288 ) and cystocele repair. Another surgeon assistedwith the procedures and also performed a rectocele repair. I know that the Correct Coding Initiative (CCI) bundles the rectocele with the cystocele, and I should not unbundle them. However, since another surgeon assisted and did the rectocele portion, should I be appending modifier 59 to unbundle the codes anyway?

Also, the other surgeon insisted he was assisting on all aspects of the surgery and plans on adding both modifiers 62 and 80. I believe these two modifiers should not be used together, as one is stating the two surgeons are both sharing the lead and the other is stating that one surgeon is lead and the other is assisting. Am I correct?

Alaska Subscriber

Answer: The answer depends on whether you are billing Medicare or other payers. However, you should code as follows.

Surgeon 1: Report 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]) for the sling procedure. Next, report 57260 (Combined anteroposterior colporrhaphy) for the anterior cystocele repair. Append modifier 62 (Two surgeons) to indicate that your doctor performed only part of 57260.

Use ICD-9 code 618.01 (Cystocele, midline) to indicate that the urologist performed the anterior and cystocele repair portion of code 57260.

Important: If there is one CPT code that encompasses more than one procedure, then you should use that comprehensive code rather than reporting two codes. In your case, however different surgeons performed the two procedures included in the one CPT code. Therefore, each surgeon should bill the same CPT code with modifier 62 and document in his individual operative report what part of the total procedure he performed.

Surgeon 2: The second assistant surgeon should first report 57260 for the rectocele repair. Again, append modifier 62 since he acted as a co-surgeon for this procedure performing part of the over all procedure. Use ICD-9 code 618.04 (Rectocele) to indicate what portion of the total procedure the second surgeon did. Then, if he did assist with the sling procedure, he should also report 57288 and append modifier 80 (Assistant surgeon).

Remember that unlike private payers that most often will reimburse for an assistant in the above scenario,Medicare will not pay an assistant fee to a surgeon who is also performing a major procedure at the same encounter.