Urology Coding Alert

Urology coders are often confused about how to code when a laparoscopic procedure switches to an open procedure. Urologists can spend a lot of time on a laparoscopy, but they cant necessarily bill for both laparoscopic and open codes. To receive proper payment, coders can append modifiers -52 (reduced services) or -53 (discontinued procedure) to the laparascopic code and bill the open code as well, or they can append modifier -22 (unusual procedural services) to the open code.

For example, a urologist attempts a radical nephrectomy via laparoscopy (50545), but because of technical difficulties with the dissection, the urologist converts to an open radical nephrectomy (50230).

Use Modifier -52 or -53

According to CPT guidelines (March 2000 CPT Assistant), surgeons should bill the laparoscopic procedure with modifier -52 or modifier -53 appended, and the open procedure.

Coding a converted laparoscopic to open procedure requires a review of the operative report to determine how much of each procedure was performed. The same review is required when coding any attempted procedure. Modifier -52 should be used when the urologist switches from laparoscopic to open at the physicians discretion. Modifier -52 signals that the conversion is done by doctor choice, says Laura Siniscalchi, RHIA, CCS, CCS-P, CPC, senior consultant with the Boston branch of Deloitte and Touche, a national auditing consultancy. CPT says to use modifier -52 if its your choice to convert to open, Siniscalchi says. The urologist will be paid about half of the fee for the laparoscopy portion of the bill, Siniscalchi says. For example, the open radical nephrectomy (50230) would be paid in full, and the laparoscopic portion (50545-52) would be paid at about 50 percent.

Modifier -53 does not necessarily result in a payment reduction, and should be used when the urologist discontinues the laparoscopic procedure because of extenuating circumstances that threaten the well-being of the patient. Do not use modifier -53 for the elective cancellation of a procedure prior to the patients anesthesia induction and/or surgical preparation in the operating suite, according to CPT 2001. Again, with reference to the nephrectomy scenario, if the urologist forgoes the laparoscopic radical nephrectomy and converts to an open procedure to control excessive bleeding, and subsequently performs an open nephrectomy, code 50230 and 50545-53.

Local Carriers Policies

Coders who have worked outside of urology get confused because they know Medicare carriers say to bill only the open code for cholecystectomies that convert from laparoscopic to open. But coders should not assume a carrier has the same rules for urological procedures as for cholecystectomies. A radical nephrectomy is not the same as a cholecystectomy and, in general, urological procedures do not have the limitations of the commonly performed cholecystectomy.

Siniscalchi recommends asking your carrier what the policy is regarding the specific laparoscopic and open procedures the physician performed, and file accordingly. Use CPT rules in the absence of local Medicare carrier policy. Report the open cholecystectomy as the primary procedure, with the modified laparoscopic code as the secondary procedure. In the absence of a specific carrier policy saying you cant bill both laparoscopic and open, you can bill them both, as CPT recommends, Siniscalchi says.

National Medicare Policy Implies Dont Bill Both

Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in Augusta, S.C., says urologists cannot bill both a laparoscopic and open procedure together according to the Medicare Carriers Manual. She refers to two paragraphs in Section 15068:

1. (Paragraph H): Most Extensive Procedures When procedures are performed together that are basically the same or performed on the same site but are qualified by an increased level of complexity, the less extensive procedure is bundled into the more extensive procedure.

2. (Paragraph I): Sequential Procedures. An initial approach to a procedure may be followed at the same encounter by a second, usually more invasive approach. There may be separate CPT codes describing each service. The second procedure is usually performed because the initial approach was unsuccessful in accomplishing the medically necessary service. These procedures are considered sequential procedures. Only the CPT code for one of the services, generally the more invasive service, should be billed.

On a more practical note, Medicare is probably concerned about what happened when laparoscopic cholecystectomies were introduced. Many physicians tried the procedure, were unable to do it and had to switch to an open procedure, while those who were already laparoscopic experts performed it easily. The expert physicians got paid for the laparoscopic procedure, while those who were less expert were seeking reimbursement for both the laparoscopic and the open procedures. Medicare didnt want to reward a physician for trying something he or she wasnt trained to do.

Use Modifier -22 for Medicare

When billing Medicare, you can code only the open procedure with modifier -22. You would have to send in the operative note with the claim, and show that the circumstances are really unusual, Siniscalchi says.

Nelda Laskey, RHIT, reimbursement coordinator for Garden City Medical Clinic, a multispecialty practice in Garden City, Kan., says her clinic only bills for the open procedure when they have to convert from laparoscopic to open. But we can use modifier -22 on the open. If the physician takes a lot of time trying to perform it laparoscopically, and decides he couldnt and has to use the open approach, put modifier -22 on the open code, Laskey says. Send in all documentation, and keep track of time.

Hospital Coding Conflicts

Also, confusion regarding how to code laparoscopic to open conversions comes from hospital coding, Siniscalchi says. Theres a longstanding rule that in hospitals, when a surgery is converted from laparoscopic to open, the hospital can only use the ICD-9 procedure code for open, Siniscalchi says. Because of this, many coders will say you can only report the open procedure code. And hospital ICD-9 coding conflicts with CPT coding in this case. A hospital would never report a laparoscopic code in addition to the open code, Siniscalchi says. But for the physician, its different. The urologist must use CPT codes, not ICD-9 procedure codes, and therefore has a different set of rules to follow.