Wiki 52224 & 52005

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Should we use XS modifier instead of the 59 if the patient has Medicare as the insurance. Thanks, AB
 
Code these together often, follow this logic below.

Question: According to Correct Coding Initiative (CCI) edits, 52005 is a component of column 1 code 52204, but coders may use a modifier to differentiate between the services the urologist provides. So when can we report both CPT Codes? The cases I am specifically looking at are:

• Patient had cystoscopy. Urologist placed a catheter and performed washings, and then removed the catheter and did a cold cup biopsy.

• Urologist performed a cystoscopy with a biopsy, and then placed a catheter.



Can I unbundle the codes in these cases?

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Answer: You are correct that CCI bundles 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation or ureteropyelography, exclusive of radiologic service) into the codes for transurethral resection of a bladder tumor (TURB) as well as 52204 (Cystourethroscopy, with biopsy). You can bypass this edit and report both CPT codes using modifier 59 (Distinct procedural service) under the appropriate circumstances.

Example: If the urologist performs a cystoscopy and retrograde pyelogram as a diagnostic study along with the TURB or biopsy codes, you may bill for both. If the cystoscopy and insertion of a ureteral catheter is to protect the ureter during the resection when the physician anticipates that a TURB or biopsy may involve the ureteral orifice, this procedure becomes an integral part of the resection or biopsy, and therefore, you should not bill separately for it.

In the two cases you describe -- obtaining urine from the upper tract for cytology via cystoscopy and ureteral catheterization and then performing a bladder biopsy -- report the following codes:

• 52204 for the bladder biopsy whether the urologist obtains one or more biopsies

• 52005-59 for the upper tract studies.
 
My interpretation of the NCCI manual's guidance on these procedures is that the modifier may be used to bypass the edit only when the two procedures are performed on a separate structures, in other words in this situation, on the contralateral ureter.

So in this example, since a cystoscopy and ureteral catheterization (including injection of contrast for a pyelogram) is already considered included in CPT 52204 per the NCCI edits, then it would only be appropriate to code both of these if the ureteroscopy with biopsy was done on one side and the ureteral catheteriziation was performed on the opposite side.
 
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thomas7331 said:
My interpretation of the NCCI manual's guidance on these procedures is that the modifier may be used to bypass the edit only when the two procedures are performed on a separate structures, in other words in this situation, on the contralateral ureter.

So in this example, since a cystoscopy and ureteral catheterization (including injection of contrast for a pyelogram) is already considered included in CPT 52204 per the NCCI edits, then it would only be appropriate to code both of these if the ureteroscopy with biopsy was done on one side and the ureteral catheteriziation was performed on the opposite side.
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I'd follow up with, review the image of the bladder with the orfice and ureters. You notice, if they biopsy an area of the bladder 52204 is done, then they insert a catheter 52005 into the ureter (no ureterscope) for the retrograde injection then this is distinct from CPT 52204.
Reason for mod 59 being allowed on my end. You can't go contralateral in the bladder. The bladder in itself is distinct from the ureter.
 
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