Urology Coding Alert

NCCI confirms that you shouldn't expect payment on new sedation codes

If you thought it was a challenge to report moderate sedation services your urologist performs with surgical procedures, now it’s nearly impossible. The latest round of edits from the National Correct Coding Initiative bundles two new moderate sedation codes (99143-99144) with five urological procedure codes.

You Can’t Unbundle Regardless of Circumstance

NCCI version 12.1 bundles 99143 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; under 5 years of age, first 30 minutes intra-service time) and 99144 (… age 5 years or older, first 30 minutes intra-service time) with the following urological procedure codes:

• CPT 50021 --Drainage of perirenal or renal abscess; percutaneous

• CPT 50382 --Removal (via snare/capture) and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation

• CPT 50384 --Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation

• CPT 50387 --Removal and replacement of externally accessible transnephric ureteral stent (e.g., external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation

• CPT 50592 --Ablation, one or more renal tumor(s), percutaneous, unilateral, radiofrequency.

All of these bundles have a modifier indication of “0,” meaning you can’t break the bundle using a modifier under any circumstances, says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook.

Conscious Sedation Edits Mirror Past Guidelines

These bundles shouldn’t be a surprise to coders, experts say. “The inclusion of moderate sedation in several codes is really a continuation of CMS’ position that anesthesia other than GA provided by the MD should not be separately reported,” says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis.

Don’t get your hopes up: Just because NCCI Edits is adding these new edits, the bundles don’t necessarily mean that Medicare plans to start paying for moderate sedation, says Margaret Loftus with Stanford Hospital & Clinics. The moderate sedation codes have no relative value units (RVUs), and Medicare has given them status C, meaning carrier-priced. “These services were historically considered bundled, and I see nothing yet that indicates they have changed their minds,” Loftus says.

Many procedures that involve conscious sedation don’t include the costs of conscious sedation in their RVUs, but carriers deny them anyway, says Carrie Ontiveros, coding specialist with the Wichita Clinic in Wichita, Kan. “CPT guidelines specifically outline which services include conscious sedation,” she adds. But physicians who perform those services “are basically providing a free service.”

Watch for These Other Bundles Targeting Urology

If your urologist performs transplants, take note of a new bundle: NCCI bundles 50323 (Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland ...) into 50325 (Backbench standard preparation of living donor renal allograft [open or laparoscopic] prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter[s], renal vein[s], and renal artery[s], ligating branches, as necessary). This bundle has a “0” modifier indicator, so you shouldn’t ever separately report the two codes.

Other NCCI 12.1 bundling edits you should take note of include:

• 50391 (Instillation[s] of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy tube [e.g., anticarcinogenic or antifungal agent]) is bundled into 50951 (Ureteral endoscopy through established ureter-ostomy, with or without irrigation, instillation, or ureteropylegraphy, exclusive of radiologic service) and 50970 (Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) with a modifier indicator of “1.” “These later procedures represent more extensive procedures, but you can unbundle these codes if circumstances warrant,” Ferragamo says.

• 51596 (Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder) now includes 50650 (Ureterectomy, with bladder cuff [separate procedure]) with a modifier indicator of “0.”

• 50391 (Instillation[s] of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy tube [e.g., anticarcinogenic or antifungal agent]) now includes 50390 (Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous), 50392 (Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous), and 50393 (Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous). These edits have an indicator of “1,” meaning that the bundles may be broken under particular circumstances.