Urology Coding Alert

The lack of a TURP code to represent the resection of residual obstructive tissue during the postoperative period continues to baffle urology coders and urologists but we've got the solution to this coding conundrum.                                   

Transurethral resection of the prostate (TURP) is a treatment used for patients presenting with benign prostatic hyperplasia (BPH), commonly referred to as enlarged prostate. BPH, a condition prevalent in men over the age of 50, is a condition of aging that can require surgical management if the symptoms and effects of the enlarged prostate become severe. BPH symptoms include, but are not limited to, frequent urination, overflow incontinence, hematuria, straining for urination, weak urine stream, and even acute urinary retention.

The TURPcode descriptors include all sorts of indications for when the codes can be used and what other services are included in the codes, but they don't meet some very common TURPcoding needs.

The circumstances are familiar: Apatient undergoes a TURPon Monday and the urologist removes the catheter on Wednesday, but the patient is unable to void so the catheter is reinserted. The catheter is removed a second time on Friday, the patient is still unable to void, and the catheter is reinserted a second time. When the patient is still unable to void the following Monday, the urologist suspects residual obstructing tissue and schedules a cystoscopic examination and a possible additional transurethral resection procedure.

But there is no code for the resection of additional tissue in the postoperative period of TURP. You can't use 52620 (Transurethral resection; of residual obstructive tissue after 90 days postoperative) because, in the above example, the resection is performed before the global period has expired, says Joy Thebodeau, CPC, coding specialist for Spartanburg Urology Associates in South Carolina.

So, what should you do?

Code Based on Status of Claim

According to Michael A. Ferragamo, MD, FACS, clinical assistant professor at State University of New York, Stony Brook, the status of your claim can determine how you should approach coding the postoperative tissue resection.

Scenario 1: You have already submitted a claim for the initial TURPprocedure, using CPT 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]).

Code 52601 describes an initial, complete TURP procedure, includes vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation and internal urethrotomy and has a 90-day global period for all Medicare carriers and the vast majority of private carriers, says James R. Fishman, MD, a practicing urologist with Central Arizona Urologists in Phoenix.

If you have already submitted a claim for code 52601, you have two options for coding the additional resection. The first option is to call the carrier and attempt to change your code selection, Ferragamo says. "If the claim has not yet been processed and you explain that a change in the patient's status has affected your code selection, you may be able to alter your coding from 52601 for the initial procedure, to 52612 (Transurethral resection of prostate; first stage of two-stage resection [partial resection])." By coding 52612 for the first service, you will be able to submit a claim for 52614 ( second stage of two-stage resection [resection completed]) for the second procedure. Using the two-stage resection codes will eliminate the problem of trying to find a code for the second resection.

Your second option if you are unable to amend your original claim is to code 52612-78 (Return to the operating room for a related procedure during the postoperative period) for the additional resection. The second  TURP was not planned, so it really constitutes the treatment of a postoperative complication: the urinary retention.

Because code 52612 represents a "partial resection," it is associated with less extensive physician work and has a lower reimbursement value, says Rosemary W. Russell, CPC, coding specialist with Maine Urology Associates in Bangor. And because you are not resecting as much tissue as is represented in code 52601, code 52612 is better representative of the service.

Ferragamo cites another reason why you should use 52612 with modifier -78 for the second procedure: "Code 52601 represents only an initial TURPprocedure. It should not be used more than once for a patient, and many carriers won't recognize a second use of 52601 as a reimbursable service."

Change Your Approach for Claim #1

Scenario 2: You have not yet submitted a claim for the initial TURPprocedure because the patient has not left the hospital and you have not yet received the operative report for the patient's stay.

"Sometimes a urology practice will wait to code a patient's hospital services until the patient has been discharged from the hospital and the operative report has been sent to the office," Ferragamo says. If this is the case and the patient required resection of residual obstructive tissue within the 90-day period, use the two-stage resection codes, 52612 and 52614, to describe the procedure, he instructs coders. By using this coding method you can again avoid trying to submit a claim for a repeat 52601 procedure.

Scenario 3: The urologist is unable to perform a complete TURPprocedure the first time and decides to do as much as possible and monitor the patient's progress. "Sometimes the surgeon may underestimate the size of the prostate and after performing a customary one-hour TURP session realizes there is considerably more tissue to resect," Fishman explains, and the urologist will plan to complete the procedure at a later date.

When a urologist decides to resect as much tissue as possible during the first TURP procedure and plans to resect additional tissue at another time, you should again use 52612 for the first procedure and 52614-58 (Staged or related procedure or service by the same physician during the postoperative period) for the second procedure, Ferragamo says.

The urologist is really saying that he will accomplish a full or total resection in two stages, the second usually falling within the global period. "Modifier -58 is required if 52614 is performed within the 90-day global period of 52612," warns Wendy Dicus, CPC, coding supervisor for Alaska Billing Services in Anchorage.

"Modifier -58 will allow full payment for the second staged procedure," Ferragamo adds.