Urology Coding Alert

You could be missing out on as much as 15 percent per procedure

If you don't know the rules for unbundling and modifying multiple cystoscopies your urologist performs on the same day on the same patient, you could be missing out on hundreds of dollars of deserved reimbursement.
 
By using modifiers correctly and adjusting, urologists can maximize their billing for these multiple claims. Confusion abounds about whether to use modifier -59 (Distinct procedural service), modifier -51 (Multiple procedures), both, or no modifier at all with multiple endoscopies.

Be an Ace of Base

Medicare has special rules for reimbursing multiple procedures when those procedures are endoscopies and include a diagnostic endoscopy or common base code. This is called the "multiple endoscopy rule."
 
In these cases, payment for a second endoscopy is based on the difference between its relative value and the base code's value, and so it goes for the third procedure. If an endoscopy is billed with another endoscopy in the same family (i.e., an endoscopy that has the same base procedure), payment for the second endoscopy is based on the difference between the fee paid for the procedure minus the fee for the base procedure.
 
If one does multiple bladder biopsies, 52204 (Cystourethroscopy, with biopsy), the first biopsy is paid in full and subsequent biopsies at full price minus the fee for the base procedure (52000, Cystourethroscopy [separate procedure]). Here are examples using the New York-area #2 fee schedule:
  52204               $146.68
  52204-59          $23.20
  52204-59          $23.20
 
The fee for the subsequent biopsies is calculated by: $146.68 (52204) - $123.48 (base fee for the cystoscopy, 52000) = $23.20.

 
The Medicare fee scale (assuming the procedure is nonfacility) would be:
  52204               $126.91
  52204-59          $19.87
  52204-59          $19.87
 
The fee for the subsequent biopsies is calculated by $126.91 (52204) - $107.04 (base fee for the cystoscopy, 52000) = $19.87.

Modifier -59 is appropriate here because it refers to bladder biopsies from different locations within the bladder and not double or triple billings. For commercial carriers, you may need to append modifier -51. However, for Medicare do not add modifier -51 - Medicare will append the modifier to the proper CPT codes when necessary.
 
Terry Vennell, CPC, billing manager for Knight, Boline & D'Amico in Harrisburg, Pa., explains. "If it's Medicare, you can bill both, and then Medicare will subtract the cost of the endoscopy from the second procedure."
 
Linda S. Dietz, RHIA, CCS, CCS-P, coding specialist of the National Correct Coding Initiative, warns that NCCI edits state that two services should be reported together using modifier -59 only if there is an extenuating circumstance, such as separate anatomic sites or separate patient encounters.
 
Dietz warns that NCCI-associated modifiers should not be used solely to indicate that both procedures were performed. "CMS is concerned that there appears to be a lack of agreement or understanding about when it is appropriate to use NCCI-associated modifiers," Dietz says. "Under the payment rules for multiple endoscopy procedures, the endo base code is never separately payable with other endoscopy codes for which it is the endo base code. Carrier processing systems should not pay CPT code 52005 (Cystourethroscopy, with ureteral catheterization ...) in addition to the listed column 1 endoscopy codes."
 
CMS includes NCCI edits with the endo base codes bundled into the corresponding endoscopy codes because it represents correct coding and informs providers about the endo base code.
 
If the payer is not Medicare, but commercial, you need to find out how it wants you to bill these procedures. Some carriers are more likely to pay than others, Vennell says.

No Shared Base Code Means Modifier -51

If multiple endoscopic procedures do not share a common base code nor form a bundled edit, code the highest-paying endoscopy first followed by the second and third procedures.
 
Medicare will properly append modifier -51 to the lesser codes and reimburse 100 percent of the highest paying and 50 percent for each of the up to five subsequent endoscopies.
 
So if a urologist performs both a transurethral resection of the prostate (52601) and a transurethral resection of a small bladder tumor (52234), Medicare will reimburse the full fee for 52601 and half of the fee for 52234-51.
 
If two cystoscopies share a common base code, it is a tad more complicated. For example, a urologist performs 52276 (Cystourethroscopy with direct vision internal urethrotomy) to open a stricture and also injects the stricture with steroids (52283, Cystourethroscopy, with steroid injection into stricture).
 
Although you should not use modifier -51 when billing Medicare for multiple procedures within the same coding family, commercial payers may have different policies.
 
Cystoscopy code 52000 is the base code for many other endoscopic procedures. But many times this code will not be billed at all. Instead, you might bill any one of the other procedure codes that encompass a cystoscopy. 
 
Again for Medicare, do not append modifier -51 in these cases - you could reduce your payment by half. Let Medicare append modifier -51 if so needed.
 
In some specific circumstances, modifier -59 is appropriate when billing multiple endoscopic procedures, such as a ureteroscopic lithotripsy for a left ureteral stone and a cystourethroscopy and right retrograde pyelogram to visualize a small stone in the left renal pelvis.
 
Usually, Medicare considers cystourethroscopy and retrograde pyelogram (52005, Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) to be included in the ureteroscopic study (52353, Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]). However, this case is special because the two procedures were performed on different kidneys for different reasons.
 
Report both 52353-LT (Left) and 52005 with modifiers  -59 and -RT (Right) with each procedure linked to the appropriate diagnosis. Do not report 52005-RT alone because -RT alone in this case may not be considered an appropriate modifier for reimbursement.

Use Modifier -76 for Multiple Cystoscopies 

In another example, a urologist was scheduled to perform a tension-free transvaginal tape (TVT) sling operation and another doctor was to perform an anterior and posterior colporraphy.
 
During the cystoscopy, the urologist found a urethral diverticulum, decided not to perform a TVT, but waited to see if the patient's incontinence resolved after the repair.
 
The urologist then left the operating room having performed only the cystoscopy. During the other procedure, the physician lacerates the urethra. The urologist must then do another cystoscopy, repair of a urethral injury, and place a suprapubic cystostomy drainage tube. Can you charge for the second cystoscopy?
 
Since the punch-trocar cystostomy (51010, Aspiration of bladder; with insertion of suprapubic catheter) and urethral repair (53502, Urethrorrhaphy, suture of urethral wound or injury, female) do not bundle or include cystoscopy, you may bill for both cystoscopies, adding modifier -76 (Repeat procedure by same physician) or possibly -59 to the second cystoscopy performed indicating the second encounter with the patient.
 
Use modifier -59 when the urologist performs procedures not usually reported together (that is, bundled) but that under certain circumstances are appropriate to report together. According to CPT, these circumstances are:

 

different sessions or patient encounter
 

different procedure or surgery
 

different site or organ system
 

separate incision/excision
 

separate lesion
 

separate injury (or area of injury in extensive injuries).

Occasionally, the urologist may do two procedures, such as hydrodilating the bladder with saline via the cystoscope, then removing the scope and letting the bladder remain full for 10 to 15 minutes, subsequently draining the solution from the bladder and reinserting the cystoscope a second time to perform a biopsy. You should also use modifier -59 under these circumstances.
 
You would file the claim 52260 (Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction [spinal] anesthesia) on the first line and 52204-59 on the second line.
 
Since the two procedures share the same base code (52000, see chart), Medicare will pay 100 percent of the most expensive procedure (in this case, 52276) and 100 percent of the second procedure (52283) minus the amount payable for the base code, 52000.