Urology Coding Alert

Don't write-off anesthesia

The American Urological Association (AUA) advises against it. Medicare won't reimburse you for it. Are there circumstances when you can report anesthesia separately from the procedure itself? Yes, says Michael A. Ferragamo, MD, FACS, assistant professor of urology, State University of New York, Stony Brook.
 
In a policy it recently issued, the American Urological Association does not advocate billing for local anesthesia for needle biopsies of the prostate - it considers anesthesia administered by the urologist included in CPT's definition of the surgical package and not a billable service.
 
Many carriers, Medicare included, will not reimburse for a periprostatic block. Check with your local carrier to determine whether it includes local anesthesia in the surgical package or if it's separately billable.
 
"Any anesthesia administered by the operating surgeon is included in the operative fee," Ferragamo says. "That means when you inject around the prostate for a prostate block - a regional area is blocked off - your anesthesia injection is included in the fee for the needle biopsy of the prostate."
 
You have two CPT codes for reporting a prostate block, depending on where the urologist administers the block and what carrier is involved.
 
If the urologist administers a pudendal block, you should report 64430* (Injection, anesthetic agent; pudendal nerve). But if the urologist administers a periprostatic block, you should report 64450* (... other peripheral nerve or branch).
 
You may need to append modifier -59 (Distinct procedural service) to 64450 depending on the corresponding procedure - the National Correct Coding Initiative bundles 64450 into most prostate procedure codes including 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) and some minimally invasive benign prostate hyperplasia treatment codes (53850, Transurethral destruction of prostate tissue; by microwave thermotherapy; CPT 53852 ... by radiofrequency thermotherapy; and 52647, Non-contact laser coagulation of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]).
 
Medicare and the AUA policy disapprove of separate reporting for a periprostatic block, but there are a few opportunities for payment, Ferragamo says.
 
"The CPT surgical package definition includes in the package local anesthesia, finger and toe block, and topical anesthesia. There's no mention in the surgical package definition of a block, what I call a regional block."
 
In fact, recently the CPT Assistant (see inset) presented a patient undergoing a circumcision and receiving a penile ring block at the base of the penile shaft and/or a dorsal penile nerve block with Marcaine. CPT indicated that this anesthesia was payable as nerve/regional blocks. For either or both blocks, use code 64450, a peripheral nerve block, Ferragamo says.
 
"So now you have Medicare telling you not to bill for prostate biopsy, and you have the AUA in agreement, so certainly for Medicare patients you should not bill. However, there are some private carriers that will pay for anesthesia administered by the surgeon, and if you don't know the surgical package the private carrier follows, you should probably bill for the prostate biopsy using code 64450."

Local Versus Regional Anesthetic

Some practices still unbundle and bill for the periprostatic block. "We choose to follow the AMA's
guidelines (see inset) instead of the AUA's, and we do that based on the fact that it is not a local anesthetic," says Morgan Hause, CPC, at Urology of Indiana. "It's a regional anesthetic, and that is supported by the AMA in CPT Assistant in an August 2003 article relative to a circumcision with penile block (see above). The AMA feels it appropriate to bill the block separately. I see absolutely no reason why that rule [on anesthesia for circumcision] would not also apply to prostate blocks."
 
Hause attributes this discrepancy between the AMA and the AUA guidelines to confusion regarding the definition of local and regional anesthetic.
 
Some carriers are paying for pudendal block 64430 for treatments in the office of benign prostatic hyperplasia using transurethral microwave thermotherapy, transurethral needle ablation, or interstitial laser coagulation (indigo laser).
 
Rachel Reyes, CPC, of Urology Associates Central in Fresno, Calif., no longer reports nerve blocks to Medicare, but will report them to private carriers. "Some of the private insurance companies, we bill them, and some of them (the major Blues and Delta) are paying for that." Some coders are more cautious. "We do not charge for that," says Cindy Schuler, CPC, of Watertown Urology in Watertown, Wis.
 
Ferragamo concludes "that if you want to follow Medicare rules you probably shouldn't be billing for any anesthesia, but for private carriers, bill for the anesthesia as you do not know their particular policy concerning anesthesia. Find out whether the carrier follows a Medicare type of policy or a CPT type of policy. My
suggestion is to bill your commercial and private carriers and HMOs for any anesthesia that the urologist administers until the carrier tells you they will no longer reimburse for the anesthesia."
 
Hause agrees: "I don't think it's something you can code on every patient, but I think it is something that needs to be considered for private payers."