Urology Coding Alert

Improper coding of ultrasounds and x-rays could cost you $242 for each prostate biopsy and $120 for each retrograde

Proper reporting of radiological guidance and supervision depends on many things -- who did the procedure, where the procedure occurred, and who owns the equipment -- but you can confidently submit claims for these services with these expert guidelines.

"If you plan to report and bill for a radiology code along with a surgery code, the urologist should dictate a full radiology report, which now may be included within the regular operative note," says Michael A. Ferragamo, MD, assistant clinical professor of urology , State University of New York, University Hospital, Stony Brook. Here's how to code a few different scenarios involving two common procedures.

Ultra-Effective Ultrasound Coding

A urologist performing 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) usually uses ultrasonic guidance to help him place the needle correctly (76942, Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation), along with a transrectal ultrasound to evaluate the prostate for abnormalities (76872, Ultrasound, transrectal).

If both of these radiological procedures are medically necessary -- and they are, in most cases -- you can separately report both. How you code the procedures depends on which of the following scenarios your documentation reflects:

1. Procedure done outside the office with a radiologist: If the urologist performs the biopsy in a hospital or other facility where he does not own the radiological equipment, and a radiologist performs and interprets the ultrasound tests, you can only report CPT 55700 for the biopsy, says Debi Wagner, CPC, biller and coder for the Southern Ohio Medical Center in Portsmouth. The facility documents the radiologist's supervision and interpretation of the imaging procedures and reports codes CPT 76872 and 76942.

2. Procedure done outside the office without a radiologist: If the urologist performs the biopsy and the imaging procedures in a hospital, using equipment he does not own, without the help of a radiologist, you can report codes 55700, 76872-26 and 76942-26, Wagner says. Modifier -26 (Professional component) shows that the urologist does not own the equipment.

3. Procedure done in the office without a radiologist: If the urologist performs the ultrasounds and the biopsy with equipment that he owns, you can report 55700, 76872 and 76942 without any modifiers, says Sue Scott, CPC, business office manager for St. Louis Urological Surgeons in Chesterfield, Mo.

"We do the procedure in the office with our own equipment," she says, "so we use all three codes without modifiers." In this case, the urologist is performing both the technical and professional components of the procedures -- in other words, the entire procedures -- and should bill for the global charges.

Crack the Retrograde Pyelogram Conundrum

The retrograde pyelogram involves two distinct procedures. CPT code 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) represents the catheterization and introduction of contrast material.

The urologist or radiologist may also interpret the images (x-ray films or fluoroscopic images) and report 74420 (Urography, retrograde, with or without KUB).

For any retrograde pyelogram, you can report 52005 for the urologist's work. As before, however, reporting 74420 depends on who interprets the study, and where this occurs.

1. Procedure done outside the office with a radiologist: In the hospital, the urologist introduces the contrast, takes the x-rays, reads the films and acts clinically according to his interpretation. Report code 52005 for the cystoscopy and retrograde pyelogram and code 74420-26 for the interpretation of the x-rays.

The radiologist is rarely ever present in the operating room or endoscopy suite to read the films, but may report code 74420-TC for the technical component.

If the radiologist alone interprets the x-rays at a later time, and the urologist does not bill for his interpretation at the time of the procedure, the radiologist should report code 74420 without any modifiers. The urologist would then only code 52005 for his services.

2. Procedure done in office without radiologist: If the urologist performs both the cystourethroscopy and the urography on equipment in his office that he owns, you can report both 74420 and 52005 without any modifiers.

Experts warn: When reporting the radiological findings of the pyelogram, remember to indicate the size of the ureteral catheter and the volume and type of contrast agent used to outline the urinary tract.

Also report the radiological findings in sufficient detail to warrant the charge you are making for reading and interpreting the study. When you're deciding whom to pay for radiological services, the Medicare Carriers Manual states, "Pay only for one reading ... and for the reading and interpretation that directly contributes to the dagnosis and treatment of the patient."

"This certainly represents the urologist's reading,"  Ferragamo says. "The radiologist's reading, usually after the fact, is purely a quality issue reading."

Make Your Case With AUA Appeal Letters

Although NCCI does not bundle 76942 with 76872 any longer, some non-Medicare carriers may still deny reimbursement for one when they are billed together. Additionally, some insurers might be reluctant to pay urologists for sonographic procedures, arguing that they aren't qualified.

The American Urological Academy has appeal letters that you can use in both situations. To download them, go online to www.auanet.org/practice_mgmt/coding_reimburse/appeal_letters.cfm.