Urology Coding Alert

Urology coders are accustomed to billing for bundled procedures, which require one code covering a specific combination of procedures. But sometimes the urologist performs only some of the procedures. When this happens, the coder may be able to submit a claim using more than one code for a session, explains Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. You need to be aware of the various available options so you can obtain maximum ethical reimbursement for your practice, says Callaway-Stradley.

Medicare, CPT and Private Payer Rules Differ

The difference is evident when looking at how Medicare, CPT and private payer rules affect coding for cystoscopy with manipulation. Many urology coders were surprised to read in the September 2000 issue of CPT Assistant that they can use codes 52005 (cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) and 52330 (cystourethroscopy [including ureteral catheterization]; with manipulation, without removal of ureteral calculus) together.

Medicare guidelines do not allow billing of 52330 with 52005 52005 is the base endoscopy code for 52330. But CPT does not recognize Medicares special endoscopy rules, and neither do some private payers. Payers that do not recognize the special endoscopy rules may allow you to bill for both 52330 and 52005, as described in CPT Assistant.

There is additional confusion when the coder has to consider also billing for a stent placement since Medicare has that code bundled into 52330, according to the CCI edits. Stone manipulation is rarely done without a stent, and the code for a stent 52332 (cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) includes 52330 under the CCI.

Finally, remember that when a stent is left behind at the end of a procedure, it is billable by using modifier -51 (multiple procedures) under CPT.

Understand Medicare Rules

The following scenario is for a Medicare patient, as explained by Michael A. Ferragamo Jr., MD, FACS, clinical assistant professor of urology at State University of New York Medical College, in Valhalla, N.Y.

Step 1: Using 52005 and 74420 with -26. A patient has a calculus lodged in the ureter, which is discovered by cystourethroscopy (52005) in combination with urography, (74420, urography, retrograde, with or without KUB). If the radiological procedure is done in the hospital but the urologist interprets the x-ray, the urologist should append modifier -26 (professional component) to the 74420. Often, says Ferragamo, the pyelogram is done in the hospital, and the urologist reads the film. [...]