Urology Coding Alert

Don't let bladder instillation procedures trip up your coding accuracy. With two similar bladder instillation codes, you're setting yourself up for denials if you aren't carefully checking your urologist's notes.

Instillations are common in urology offices, so knowing which code to report is essential. As long as you know the bundling rules and type of drug your urologist is using, you'll code these claims like an ace every time.

Urologists commonly perform bladder instillations to treat a variety of conditions. Your keys to choosing the proper code for the instillation are the patient's diagnosis and the types of drugs the physician uses.

Often physicians use bladder instillation to treat interstitial cystitis (IC). For this form of instillation, you'll report the procedure using 51700 (Bladder irrigation, simple, lavage and/or installation).

"We use 51700 for our IC treatments and then charge J codes for the drugs," says Teresa A. Dailey, CPC, coding specialist for Urology Center of Spartanburg in South Carolina.

Other types: For bladder instillation of anticarcinogenic agents like BCG, you should report 51720 (Bladder instillation of anticarcinogenic agent [including retention time]).

Good news: "Coding instillation services shouldn't be tricky, as long as you know the patient's diagnosis," says Karen Delebreau, CPC, PCS, coder with BayCare Clinic Urological Surgeons in Green Bay, Wis.

Beware: Insurance carriers will only reimburse for instillations performed every seven days and will not pay if your urologist repeats instillations sooner than the seven days.

You should report the appropriate J codes for the drug your urologist uses for the instillation. "For example, BCG is an anticarcinogenic that goes with 51720, whereas Heparin and Marcaine for an IC treatment go with 51700," Dailey says.

Example: You should report Bacille Calmette-Guerin (BCG) with J9031 (BCG live [intravesical], per instillation) for the full vial, including any portion that was instilled and the wasted portion. For Heparin, use J1644 (Injection, heparin sodium, per 1,000 units), and for Marcaine report J3490 (Unclassified drugs), reflecting the number of units used in the appropriate box on the CMS-1500 form for any drug.

Key: Get your urologist to document exactly why he's performing the instillation and the drugs he's using. "We ask that the procedure description includes the fact that the meds are being instilled into the bladder via a catheter, and that the med strength and dosage are clearly stated," Delebreau says.

Pointer: The diagnosis you report for the instillations should be 233.7 (Carcinoma in situ, bladder) or 188.x (Malignant tumor of bladder). Most payers will accept these diagnoses as proof of medical necessity for the instillations but usually will not accept V10.51 (Personal history of bladder tumor). CPT coding policy dictates that you should use one of the above diagnoses even if your urologist administers the treatments prophylactically.

To perform an instillation, the urologist uses a catheter. You cannot separately report the catheter insertion (51701, Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]). Both 51700 and 51720 include the catheter, Dailey says. You shouldn't report the catheter supply either. "We consider supplies used to be included with the procedure," Delebreau says. "Most carriers will not pay for supplies separately."

You often won't be able to separately report an E/M service either. If the patient is just in your office for the instillation, you'll only report 51700 or 51720. But if the urologist documents a separately identifiable E/M service, you should report the appropriate-level E/M code, such as 99213 (Office or other outpatient visit for the E/M of an established patient ...). Append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to show that the office visit was a separate service.

Example: "We have a treatment clinic as part of our office, so we don't normally bill a separate E/M service since it's only a nurse that the patient sees and does the treatment," Dailey says. "Also, we have found that the majority of our carriers don't reimburse for a 99211 E/M service. If the patient does see a physician the same time they have an instillation done, we do bill for the separate E/M service and it's a 50/50 chance we'll be reimbursed for the E/M service."

Remember: If the urologist, physician assistant or nurse reviews with the patient any previous side effects or reactions the patient may have had following a previous instillation and notes these in the medical records, then from this review the urologist decides to proceed with the next instillation, you should report an E/M service. Use the appropriate-level established patient office visit code -- 99212 for the urologist or physician assistant and 99211 for the nurse, billed in the physician's name. Append modifier 25 to indicate a separate service.