Urology Coding Alert

Including an explanatory report could be your key to getting paid

Just because your urologist performs a procedure doesn't mean you're always going to find an exact code descriptor to match it. So what do you do when CPT Codes doesn't have a specific code for a procedure you're reporting? Turn to unlisted codes -- but make sure you follow these simple steps to show your carrier what to do with your unlisted-procedure claim.

Step 1: Never Select a 'Close but not Quite' Code

You should never report a code that comes close to the procedure your urologist performed, but doesn't quite fit. If no precise procedure or service code exists, you should report the service "using the appropriate unlisted procedure or service code," state the CPT Instructions for Use in the CPT manual.

CPT includes unlisted-procedure codes to allow you to report procedures for which there is no specific CPT descriptor available. Payment for such claims, however, is not automatic. Your urologist must make a careful effort to document the procedure, and the information you include with your claim can make all the difference.

Step 2: Explain the Procedure in Layman's Terms

Any time you file a claim using an unlisted-procedure code (for example, 55899, Unlisted procedure, male genital system or 58999, Unlisted procedure, female genital system [nonobstetrical]), you should include a separate report that explains, in simple, straightforward language, exactly what the physician did.

Part of your job when coding and preparing the claim is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman's terms. You may even want to include diagrams or photographs to better help the person reviewing your claim understand the procedure.

"When reporting unlisted codes, I would suggest doing everything you can to make sure you get paid what you think is appropriate," says Denae M. Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw, Mich. "Overload the payer with information and always give them a way to contact you with questions," she adds.

Why: Your payers will consider claims with unlisted-procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide. Unfortunately, claims reviewers frequently do not have a high level of medical knowledge, and physicians don't always dictate the most informative notes.

If the person making the payment decision doesn't understand what the physician did, your reimbursement probably won't properly reflect the effort involved, says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J.

Supply documentation: Since most carriers will no longer accept paper claims, submit your unlisted CPT code electronically with a short description of what was done in box # 19 of the CMS-1500 form or its electronic equivalent. Some carriers will then expect a faxed copy of your documentation after seven to ten days or will request documentation after receiving the electronic submission. When submitting an unlisted-procedure claim, your documentation should include the complete operative note and an explanatory cover letter.

"I also recommend first sending in the claim electronically without the documentation so that you have proof of timely filing, and then sending the documentation with a statement on the claim saying that this is a 'documentation copy, not a duplicate copy,'" Cobuzzi says.

Step 3: Reference an Existing Code

Unlisted procedure codes do not appear in the Medicare Physician Fee Schedule, so they do not have assigned fees or global periods. Your payers will generally determine payment for unlisted-procedure claims based on the documentation you provide. You can suggest a fee by comparing the unlisted procedure to a similar, listed procedure with an established reimbursement value. "It helps put your service in perspective with something they are familiar with," Merrill says.

Best bet: Rather than leave it up to the insurer to determine which code is the closest to what your urologist performed, you should explicitly make reference to the nearest equivalent listed procedure. After all, the treating physician is best equipped to make this determination.

Tell the carrier how the procedure you're coding for compares to, and differs from, the assigned procedure code, Cobuzzi advises. Answer these questions: "Was the unlisted procedure more or less difficult than the comparison procedure? Did it take longer to complete and, if so, by how much (try to provide percentages whenever possible)? Was there a greater risk of complication? Will the patient require a longer recovery and more postoperative attention? Did it require special training, skill or equipment?" Any of these factors can make a difference in the reimbursement level you may expect.

Example: Your urologist injects Botox into the patient's bladder to treat an overactive bladder. There is no specific code for this procedure. As suggested by CMS, you should report 53899 (Unlisted procedure, urinary system) for the Botox injection into the bladder. You should submit a detailed report to your carrier and compare, or benchmark, this procedure to 51715 (Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck) and 52327 (Cystourethroscopy [including ureteral catheterization]; with subureteric injection of implant material) with respect to the surgical work done, technology and equipment used, and time involved.

Step 4: Appeal When Warranted

Even the best documentation won't always get you the reimbursement your urologist deserves for an unlisted procedure. "If payment is not appropriate, it may need to be appealed," Cobuzzi says.

If your urologist uses equipment and techniques that have no dedicated CPT codes, such as the cyberknife technique for prostate treatment, you may be able to enlist the manufacturer's aid to receive appropriate reimbursement. Manufacturers often maintain free information and helplines to advise physician practices on how to approach insurers regarding new technologies.

"Sometimes manufacturers' representatives will have helpful documentation about the equipment or technique that you could use as a second resource, but don't rely on them to assist you with the coding aspect of the service," Merrill cautions.

You can also turn to specialty societies such as the American Urological Association (AUA) for help with appeals and documentation.

Good practice: When your urologist repeatedly performs the same type of unlisted procedure, prepare an information file so you don't have to reinvent the wheel every time you submit a claim. Each time a carrier denies a similar claim, you will already have an appeals packet ready to send the payer to defend your claim.