Urology Coding Alert

Urologists frequently wonder if they can bill for an endoscopic and surgical procedure at the same surgical session. If you start a procedure endoscopically but it fails and you need to do it as an open procedure, you can bill for the open procedure only. But if the endoscopic procedure is done diagnostically, and you consequently decide to do an open procedure, you can bill for both with the proper modifier.

You can bill for both procedures, says Michael Ferragamo, MD, a coding expert who practices with Ferragamo, Bruno, Efros, a three-urologist practice in Garden City, N.Y. But youll need to explain what you did, and youll need to use a modifier.

Diagnostic vs. Exploration

The key to getting paid for both procedures lies in the difference between the endoscopic procedure that failed and the endoscopic procedure that was diagnostic. When an endoscopy is a diagnostic service, and a decision for surgery is made based on it, then you can bill separately, says Cynthia Jackson, RRA, CPC, coding specialist for Emory Clinic Urology Group, a five-provider practice in Atlanta. But you need to use modifier -59 (distinct procedural service) to show that the diagnostic endoscopy is different from the surgical treatment, she adds. For example, if you tried to perform a diagnostic ureteroscopy, and then you ended up doing an open procedure, you would bill 52335-59 and the appropriate code from the open series (50610-50630).

Jackson stresses that surgeons cannot be paid for exploring the surgical field. What is the difference between a diagnostic endoscopy and exploration? If they know when they go in there what is there, then its exploring the surgical field, says Jackson. If they dont know or if they find something different from what they thought was there so they need to convert to an open procedure, then its diagnostic.

You may perform an endoscopy to determine whether you can perform the procedure endoscopically. In this case, you can get paid for both, says Ferragamo, because the endoscopic procedure is a procedure to help you determine the approach.

Unsuccessful Ureteroscopy

For example, a patient has a calculus (592.1) that you worked on for two hours using the ureteroscope. It just wont come out, and you have to write a note in the report saying that you decided to convert the procedure to an open procedure so that it could be billed. You do a ureterolithotomy [an open procedure], and thats the only code you can use, not the ureteroscopy, says Ferragamo. So you would bill 50610 (ureterolithotomy; upper one-third of ureter), 50620 (middle one-third of ureter), or 50630 (lower one-third of ureter), depending on where the stone was. But you should append a modifier -22 (unusual procedural [...]