Practice Resources

Questions and Answers

- Evaluation and Management (E&M) Services
- Preoperative and Postoperative E&M Services
- Stents and Catheterization Procedures
- Biopsy and Ultrasound Procedures
- Cystoscopy/Ureteroscopy/Endoscopy Procedures
- Urological Surgery Procedures
- Radiological Procedures
- Skilled Nursing Facility
- Denials for PSA
- Miscellaneous

Evaluation and Management (E&M) Services

Q. A patient was seen in our office during the day for hematuria. Patient was evaluated, treated and released from the office. Later that same evening, the patient called the on call urologist in acute pain, the patient was admitted to the hospital that same evening. Can we bill for a separate evaluation and management service for the office and the hospital admission?

A. A separate office visit and admission code cannot be billed on the same day. Bill for the hospital admission only. However, the evaluation performed at the office visit earlier in the day can be added to the work of the admission service and the admission service can be billed at a higher service level if properly documented.

Q. A patient is admitted to the hospital by the urologist for pyelonephritis. He has no procedure with a global during his hospital stay of seven days. How do I charge for each day's visit by the urologist and for the discharge of the patient from the hospital?

A. The admission by the urologist is charged on the first day of the hospital stay with the appropriate level of the Initial Hospital Care CPT^® Codes (99221-99223). Since the patient was seen by the urologist each day, the patient can be billed for subsequent hospital care for the evaluation and management services performed each day (CPT^® 99231-99232) based on the level of services performed and documented. On the final day, the urologist can bill for the hospital discharge services (99238 - 30 minutes or less or 99239 - more than 30 minutes).

Q. How do you bill when a nonphysician provider (NPP) performs an incident to service to a Medicare patient while there is a physician in the office suite?

A. The services should be billed under the physician's PIN number for 100 percent reimbursement of the physician's fee schedule. When the ordering physician (the physician who originally saw the patient and outlined a treatment plan) is not the same as the supervising physician (the physician who was in the office the day of the visit), CMS 100-4, Transmittal 148 clarified that it is acceptable for another physician in the same group to provide direct supervision when the ordering physician is not present in the office.

A nurse practitioner or a physician assistant can also serve as an ordering or supervising provider. If you are billing under the nurse practitioner or physician assistants' PIN number, services provided by other medical staff can be billed incident to the NPP services. The same requirements for ordering and supervising provider apply to the CMS 1500 form.

When billing, make sure the proper physician's name appears on the CMS 1500 form.

1. The ordering physician's name goes in Box 17.
2. The ordering physician's UPIN goes in 17a.
3. The supervising physician's PIN goes in Box 24(K).
4. The supervising physician signs in Box 31.
5. The group's PIN goes in box 33.

Further information on "incident to" billing requirements can be found at CMS 100-4, Transmittal 148.

Click here for more information on "incident to" billing. Go to Medicare Carriers Manual, Part 3 Claims Processing, Section 2050.

Q. We saw a patient several years ago and he recently came back for a follow-up visit. How do you distinguish a new patient from an established patient?

A. If a patient has not been seen (face-to-face contact) by any physician in your office for three years, then that patient should be considered a new patient.

Revised! (8/06)
Q. An emergency room physician recommended that a patient with left flank pain see a urologist. Is this considered a consultation?

A. This scenario would not be considered a consultation. According to Medicare, the requirements for a consultation (CPT^® codes 99241-99275) as outlined in the Claims Processing Manual, Chapter 12, Section 30.6.10:

• Specifically, a consultation service is distinguished from other evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in the State in which he/she practices. Applicable collaboration and general spervision rules apply as well as billing rules;

• A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient's medical record and included in the requesting physician or qualified NPP's plan of care in the patient's medical record; and

• After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.

Because the physician is not going to send his findings to the emergency room physician, this would not be considered a consultation. Bill the encounter as either a new or established patient visit.

Click here for more information on Consultations.

New! (8/06)
Q. As of January 1, 2006, hospital follow up inpatient consultation codes (99261 - 99263) were deleted. What codes do we use when the physician must see the patient for follow-up after an initial consultation in the hospital? Nursing Home?

A. In the hospital setting, following the initial consultation service, the Subsequent Hospital Care codes (99231 - 99233) shall be reported for additional follow-up visits.

In the nursing facility setting, following the initial consultation service, the Subsequent Nursing Facility (NF) Care codes (new CPT^® codes 99307 - 99310) shall be reported for additional follow-up visits. Effective January 1, 2006, CPT^® codes 99311 - 99313 are deleted and not valid for Subsequent NF visits.

New! (8/06)
Q. What CPT^® code do we report for a subsequent visit in the office or outpatient setting after an initial consultation?

A. In the office or other outpatient setting, following the initial consultation service, the Office or Other Outpatient Established Patient codes (99212 - 99215) shall be reported for additional follow-up visits. The CPT^® code 99211 shall not be reported as a consultation service. The CPT^® code 99211 is not included by Medicare for a consultation service since this service typically does not require the presence of a physician or qualified NPP and would not meet the consultation service criteria.

New! (8/06)
Q. Is it true that confirmatory consults or second opinion codes have been deleted as of January 1, 2006. How do I bill for a "second opinion?"

A. Effective January 1, 2006, the Confirmatory Consultation codes (99271 - 99275) have been deleted.

A second opinion is generally performed as a request for a second or third opinion of a previously recommended medical treatment or surgical procedure.

In both the inpatient hospital setting and the nursing facility (NF) setting, a request for a second opinion would be made through the attending physician or physician of record. If an initial consultation is requested of another physician or qualified NPP by the attending physician and meets the requirements for a consultation service (as identified in previous question) then the appropriate Initial Inpatient Consultation code shall be reported by the consultant. If the service does not meet the consultation requirements, then the E/M service shall be reported using the Subsequent Hospital Care codes (99231 - 99233) in the inpatient hospital setting and the Subsequent NF Care codes (99307 - 99310) in the NF setting.

In the office or other outpatient setting, report a request for a second opinion by a physician or qualified NPP, with the appropriate Office or Other Outpatient Consultation (new or established patients) codes (99241-99245) for initial consultation service. If the request for a second opinion is requested by the patient and/or family, report to the Office or Other Outpatient new patient codes (99201-99205) for a new patient and established patient codes (99212-99215) for established patients. A new patient is anyone who has not had a face-to-face encounter with any physician in the practice for more than three years.

A second opinion evaluation service to satisfy a requirement for a third party payer is not a covered service in Medicare. A second opinion E/M service initiated by a patient and/or family is not reported using the consultation codes. Some commercial payers will recognize a second opinion when a -32 (Mandated Services) modifier is appended to the E/M service.

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Preoperative and Postoperative E&M Services

Q. A urologist performed a transurethral resection of the prostate (TURP). Ten days later, the patient was admitted to the hospital for chest pain. The family doctor asked the urologist to evaluate the patient's intermittent hematuria. Is this considered a consultation?

A. The patient is only 10 days postoperative and has hematuria, this is not considered a consult. Hematuria can be a normal occurrence of the original TURP. This visit should not be billed separately, as it is included in the global period of the TURP.

Q. Can you charge an admission code for a patient scheduled for a radical prostatectomy? Can you charge for a discharge visit?

A. You may not charge either admission or discharge. The CPT^® surgical package definition includes the following:

• local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
• subsequent to the decision for surgery; one related E&M encounter on the date immediately prior to or on the date of the procedure (including history and physical)
• immediate postoperative care, including dictating operative notes, talking with the family and other physicians
• writing orders
• evaluating the patient in the postanesthesia recovery area
• typical postoperative follow-up care

The admission and discharge are included in this surgical package definition.

New! (8/06)
Q. My urologist has a patient who has prostate cancer. The patient wants to go to a large teaching facility to have his prostatectomy performed. The patient will come back to our office for post op follow up. How can we get reimbursed for the follow up? Isn't this included in the surgery?

A. Generally, if a surgeon performs the preoperative, surgery and postoperative care, the surgical CPT^® code would be billed globally and no modifier would be necessary. However, since the services in this surgery are being performed by different individuals, modifiers will be necessary to ensure payment for both surgeons.

In this case, it is imperative that coordination with the surgeon's office is done to ensure reimbursement of the work in the postoperative period of the surgery. All involved must agree on the code being billed and the appropriate modifiers appended to the surgery code to represent the services performed.

Modifiers

• -54 for surgical care only
• -55 for postoperative management only
• -56 preoperative management only

There must be an agreement for transfer of care between the physicians prior to the surgery. If the transfer of care does not occur, the services should be reported by the appropriate E/M service.

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Stents and Catheterization Procedures

Q. A patient came to our office for a stent exchange. How do I bill for the removal and reinsertion of bilateral stents in the office?

A. As of October 1, 2001, CCI edits included (bundled) the code for the removal of the stent, CPT^® code 52310, Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple and its counterpart CPT^® code 52315, complicated into the insertion CPT^® code 52332, Cystourethroscopy, with insertion of indwelling ureteral stent (e.g., Gibbons or double-J type). Separate reimbursement is no longer allowed for a stent removal performed on the same day under any circumstance. No modifier may be used to unbundle these codes. For commercial payers, reimbursement will depend on any contractual agreements and internal bundling rules. It is appropriate to bill the CPT^® code 52332 with modifier -50, Bilateral Procedure, to indicate the procedure was done bilaterally.

Q. How do you charge for stent removal when the urologist did not perform a cystoscopy and removed the stent just by pulling the string?

A. There is no CPT^® code for stent removal by string. The urologist should not bill separately for this procedure. This type of removal would be included in an associated E&M service.

If the removal was performed in the postoperative global period of a prior surgery, the removal is included in the postoperative care and is not reimbursed.

Q. How do you code for teaching patients to perform clean intermittent catheterization?

A. This teaching is included in the E&M service.

Q. An office medical employee changed a Foley catheter while the doctor was in the office. Can we bill for this?

A. Yes, if a qualified provider (a physician or nurse practitioner billing under her own number) is in the office, the changing of a urinary Foley catheter or suprapubic catheter may be charged under incident to requirements. For changing of a urinary catheter use CPT^® code 51702, Insertion of temporary indwelling bladder catheter; simple (e.g., Foley) or CPT^® code 51703, complicated (e.g., altered anatomy, fractured catheter/balloon). For changing of a suprapubic catheter, use CPT^® code 51705, Change of cystostomy tube; simple or CPT^® code 51710, complicated.

Q. Prior to April 1, 2007, I performed a ureteroscopy to treat a stricture and inserted a ureteral stent. The Medicare Explanation of Benefits (EOB) denied payment for the stent insertion as a component of another procedure. What did I do wrong?

A. Whenever billing Medicare for multiple procedures, first check the CCI edits to see if the procedures are bundled. Under CCI, CPT^® codes are labeled as either a column 1 or a column 2 code. In the past CCI edits detailed that one procedure was a component of a more comprehensive procedure and therefore should not be billed and reimbursed separately. The edits were changed because CMS and the CCI contractor decided that some procedures should not be billed together. Column 2 codes have a subscript modifier, which indicates if the use of a modifier to override the edit is appropriate. A subscript 0 modifier indicates that under no circumstances can the two codes be billed together. A subscript 1 modifier indicates that the two codes may be billed together with the use of a proper modifier. (Refer to Section 1, Coding Basics, for a complete explanation of CCI.)

The CPT^® code for an insertion of a ureteral stent is listed as a Column 2 code (with a subscript 1 modifier) to the CPT^® code for ureteroscopy. If both procedures are considered medically necessary and are documented as such in the patient's chart, then the component code can be reimbursed separately with the use of modifier -59, Distinct Procedural Service (e.g., different encounter, different organ, different site of service, etc.). Bill CPT^® codes 52352 and 52332 with modifier -59.

If there is no edit for the two codes, then they may be billed together without modifiers. An example would be an extracorporeal shock wave lithotripsy (ESWL) (CPT^® code 50590) with an insertion of a ureteral stent (CPT^® code 52332). CCI does not list the stent insertion as a component of the ESWL thus CPT^® codes 50590 and 52332 may be billed together.

If there is a subscript 0 indicator on the component code, under no circumstances can these two codes be billed together. An example would be a cystoscopy (CPT^® code 52000) and a catheterization (CPT^® code 51701). The catheterization is considered an integral part of the cystoscopic procedure and, therefore, will not be reimbursed.

CCI edits are now published for free on CMS's web site and available on www.auacodingtoday.com.

Q: Is it true that as of April 1, 2007, CCI no longer bundles cystoscopy with stent insertion with certain cystoscopy/ureteroscopy codes?

A: Yes, the CCI Version 13.1 effective April 1, 2007 will delete a number of edits for cystoscopy with stent insertion is performed with certain cystoscopy or ureteroscopy procedures. No modifier will be necessary when these procedures are performed at the same operative session. However, one note: when the procedures are performed during the same session, they will be subject to the multiply procedure reduction. Therefore, no modifier will be necessary when billing these codes for Medicare. For commercial carriers, a -51 multiple procedure modifier may be necessary.

The following CPT codes considered Column 1 procedures will no longer include an edit for 52332 cystourethroscopy with insertion of indwelling ureteral stent (eg, Gibbons or double J type).

This change was a result of the revision to the Ureter and Pelvis Guidelines in the Transurethral Surgery Section of the American Medical Association CPT Manual which more clearly defined the difference between temporary catheters and self-retaining ureteral stents.

Q. How do I bill for urinary bladder catheterizations?

A. There are several codes for this procedure. A brief description of each follows:

CPT^® code 51701, Insertion of non-indwelling bladder catheter (e.g., straight catheterization for residual urine)

This code is used when a non-indwelling bladder catheter is inserted and immediately removed after urine is obtained for diagnostic purposes, i.e., sterile urine specimen (commercial payers only) or a post-voiding residual urine (commercial or Medicare).

CPT^® code 51702, Insertion of temporary indwelling bladder catheter; simple (e.g., Foley)

Use this code for the routine insertion of an indwelling bladder catheter, such as a Foley. The patient will leave the office with the catheter in place using leg bag drainage.

CPT^® code 51703, Insertion of temporary indwelling bladder catheter; complicated (e.g., altered anatomy, fractured catheter/balloon)

Use this code when the insertion of an indwelling bladder catheter cannot be performed easily due to altered anatomy or if an already inserted catheter cannot be removed because of a defect in the catheter itself, i.e., fractured catheter/balloon. The determination of difficulty should be made by the physician who successfully passes the catheter. For example, this code is not appropriate if another health care professional cannot insert the catheter and the urologist then easily inserts it. This code should only be used for difficult insertions.

HCPCS code P9612, Catheterization for collection of specimen, single patient, All places of service.

This is an existing HCPCS code used for Medicare claims only when the urine specimen is obtained from a patient using a straight catheter. The specimen is then used in a urinalysis, urine culture or sensitivity study. Do not use CPT^® code 51701 for a specimen obtained by catheterization for Medicare claims.

New! (8/06)
Q. What is the difference between temporary and permanent stents?

A. According to CPT^® definition in the guidelines of the Ureter and Pelvis section, temporary stents are those that are inserted at the beginning of a surgical procedure and then removed once the procedure has been completed. A permanent stent is a stent that is inserted during the surgery but will be removed at a later date.

However, this wording reflects the fact that in the early days of endo-urology, all catheters inserted into ureters were referred to as "stents" and the two terms were used interchangeably. Subsequently technology has evolved and virtually all stents are designed to remain indwelling in the patient. Ureteral catheters, on the other hand are typically inserted and removed in the same therapeutic intervention.

Temporary ureteral catheters are open-ended straight tubes which are placed within the ureter to perform retrograde pyelography or to collect selective ureteral urine for cytologies. The insertion of a temporary ureteral catheter (referred to in the current guidelines as a "temporary stent") would be appropriately reported with CPT^® code 52005 and would involve insertion and removal of a catheter at the same patient encounter. In contrast, insertion of an indwelling or non-temporary stent (CPT^® code 52332) involves the placement of a specialized self-retaining stent (e.g. J stent) into the ureter to relieve obstruction or treat ureteral injury. This requires a guidewire to position the stent within the kidney. The ends of the stent are coiled so that one end is anchored in the renal pelvis while the other is in the bladder thereby preventing migration. These indwelling stents are not removed at the same patient encounter. It follows that when CPT^® code 52332 is reported with any of the codes in this family (52320-52355) it is being used to report insertion of an indwelling stent, and not a temporary ureteral catheter (52005). It would be expected that the operative procedure note would reflect the appropriate procedures performed.

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Biopsy and Ultrasound Procedures

Q. What is the proper CPT^® code for a post-voiding bladder residual ultrasound (PVR)?

A. When performing a post-voiding residual urine ultrasound, use CPT^® code 51798, Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging. However, the AUA Coding and Reimbursement Committee has established that no matter which type of ultrasound machine (imaging or non-imaging) is used to perform the diagnostic procedure, if the intent is to obtain a PVR, then use CPT^® code 51798.

There are many commercial carriers who do not recognize that CPT^® code 51798 has a XXX global and therefore no global period applies. This procedure should be treated as a radiological procedure and be reimbursed in addition to any surgical procedure or E&M service. If denials are made for this reason, append modifier -25, Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service, to the E&M service and appeal the denial. The AUA has developed appeal letters for assistance in asking the carrier to address the denial of the PVR when billed along with the E&M service. Contact the AUA's Coding Hotline at 866-746-4282 (option 2) or download the letter from www.auanet.org (under Practice Management).

Q. Can I bill for a Post Voiding Residual Urine by ultrasound and for a catheterization at the same visit?

A. Yes, you can bill these separately for Medicare patients. As of 7/1/04, CCI edits were changed to allow the billing and separate reimbursement of a PVR (CPT^® 51798) and a catheterization (51702) during the same encounter. During this same time, CPT^® 51701 was also deleted from the CCI edits.

Revised! (8/06)
Q. Prior to transrectally guided prostate biopsy, my urologist performs a transrectal ultrasound to establish medically necessity to proceed with the prostate biopsy. The CPT^® codes billed are transrectal ultrasound (CPT^® 76872), the sonographic guidance (76942) and prostate biopsy (55700). Some insurance companies are bundling the two ultrasound codes as incidental. Is there something we can do to convince carriers to pay these three codes?

A. This has been an issue for many years. Some insurance carriers continue to bundle the two ultrasound codes. Aetna was one of those carriers who bundled the two ultrasound codes together. The AUA and Aetna established communication on this issue and Aetna has now decided not to bundle the ultrasound codes together. One condition; however, to make sure each procedure is separately documented. The AUA has established a Transrectal Prostate Ultrasound and Prostate Biopsy Report to capture all the information to establish medical necessity and adequately document the three CPT^® codes performed when performing a TRUS and ultrasonic guided prostate biopsy.

The AUA also has a series of letters to assist urology offices with appeals on this type of claim. The letters can be found here. One of the letters developed covers the appropriate use of CPT^® codes for transrectal ultrasound and ultrasonic guided prostate biopsy. If your commercial contract specifically excludes the diagnostic ultrasound code, request a modification to your contract.

Revised! (8/06)
Q. Before I perform a transrectal ultrasound (TRUS) and biopsy, I inject an anesthetic agent into the prostate. Can I charge for anesthetic injection?

A. Some urologists are injecting Xylocaine or some other type of local anesthetic into the prostate. The AMA includes "local infiltration, metacarpal/metatarsal/digital block or topical anesthesia" as part of the description of the CPT^® Surgical Package Definition. This type of injection would be considered local infiltration. According to the National Correct Coding Initiative, Chapter I, General Correct Coding Policies state:

G. Anesthesia Service Included in the Surgical Procedure
Under the CMS Anesthesia Rules, Medicare does not allow separate payment for the anesthesia services performed by the physician who also furnishes the medical or surgical service. In this case, payment for the anesthesia service is included in the payment for the medical or surgical service. For example, separate payment is not allowed for the surgeon's performance of local, regional, or other anesthesia including nerve blocks if the surgeon also performs the surgical procedure.

However, private payers are inconsistent in their reimbursement of this procedure. Contact the insurance carrier to determine if this type of injection is a covered service prior to the procedure. If not covered, obtain a signed waiver to keep in the patient's chart.

Note: There is some controversy on the billing of the nerve block, 64450 Injection, anesthetic agent; other peripheral nerve or branch with a transurethral ultrasound (TRUS) and ultrasonically guided biopsy. The AUA Coding & Reimbursement Committee met at the Annual Meeting in San Francisco in May 2004 and updated their recommendation that if the urologist is performing a nerve block (injecting a numbing agent into the nerve bundles outside the prostate) on a Medicare patient, they should not bill the CPT^® code 64450 with the TRUS with biopsy. However, it may be appropriate to bill commercial carriers for the peripheral block along with the TRUS and biopsy. Reimbursement, however, will be based on contract agreements and coverage issues with each carrier.

New! (8/06)
Q. How do I bill for a saturation biopsy?

A. Saturation biopsy using prostate mapping is performed to identify the exact location of each biopsy core. Each core (approximately 20-40) is marked individually to identify the exact location and the extent of the tumor for further treatment of prostate cancer. Use CPT^® Category III tracking code, 0137T Saturation sampling for prostate mapping. Do not bill the ultrasonic guidance code with the saturation biopsy.

Be aware that many carriers will not cover this type of procedure and may deny reimbursement. Contact the carrier to determine their policy.

New! (8/06)
Q. The urologist performed a transrectal ultrasound on a patient prior to a transurethral needle ablation (TUNA), transurethral microwave thermotherapy (TUMT) or interstitial laser coagulation (ILC) procedure to determine the size of the prostate. He describes this as a "prostate volume study." How do I code for this?

A. The performance of a transrectal ultrasound prior to a TUNA is not considered a "prostate volume study." A true prostate volume study includes 5 mm cuts and views. There is a CPT^® code for a prostate volume study performed prior to brachytherapy treatment. However, to code for a TRUS prior to TUNA, use CPT^® code 76872, Transrectal ultrasound, prostate.

New! (8/06)
Q. How should I code for a prostate volume study prior to brachytherapy and the transperineal radioactive seed implant?

A. When the urologist performs an ultrasound for prostate volume study (to determine prostate size and plan for needle placement of seeds) before the surgery, code this service with CPT^® code 76873, Echography, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure).

The radiotherapist should bill separately for their part.

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Cystoscopy/Ureteroscopy/Endoscopy Procedures

Q. How do I bill for a cystoscopy with retrograde pyelogram performed on both ureters?

A. Billing rules are different between Medicare and commercial insurers.

According to the Medicare Carriers Manual, Section 15200, there are specific instructions for billing a bilateral retrograde pyelogram:

Cystourethroscopy with ureteral catheterization with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service (CPT^® code 52005) - there is no payment adjustment for bilateral procedures because the basic procedure is an examination of the bladder and urethra (cystourethroscopy) which are not paired organs. The work relative value units (RVU) assigned take into account that it may be necessary to examine and catheterize one or both ureters. No additional payment is made when the procedure is billed with modifier -50, Bilateral.

Commercial carriers may have their own rules on coding bilateral retrogrades. Contact your carrier to determine their billing requirements.

Revised! (8/06)
Q. When billing for a transurethral resection of a bladder tumor (TURBT) (52240, Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s), can you bill for a retrograde pyelogram along with the resection?

A. Retrograde pyelogram - For a Medicare patient, bill CPT^® code 52005, Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service, along with CPT^® code 52240, Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of: LARGE bladder tumor(s). Append modifier -59, Distinct Procedural Service, to CPT^® code 52005. The same holds true for CPT^® codes 52234 and 52235. There has to be a specific medical necessity to bill for the 52005. If the 52005 is used to locate the lesion in the bladder then it is considered inherent to the TURBT. If you are performing the cystourethroscopy with the retrograde pyelogram as a diagnostic to check for lesions in the ureter, then bill the 52005 with the -59 modifier.

Q. Can you also bill for a biopsy with the TURBT?

A. Biopsy of the bladder is included in CPT^® codes 52234, 52235 and 52240. According to CCI edits, the biopsy code (52204) can be unbundled for a legitimate medically necessary reason. In this case, if you are taking biopsy specimens around the tumor site, this is included. However, if you are taking biopsies in another location of the bladder from the lesion, then append -59 to 52204, Cystourethroscopy, with biopsy. As always, medical necessity should be documented for the performance of each procedure.

Q. My urologist has a patient with cancer in the ureter. He wants to instill BCG into the ureter through an established nephrostomy? Is there a CPT^® code to describe this procedure?

A. As of January 1, 2005, a new CPT^® code was created to capture this procedure. Use CPT^® code 50391 Instillation(s) of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy tube (eg., anticarcinogenic or antifungal agent).

Q. How to bill for a percutaneous nephrostolithotomy?

A. When billing for a percutaneous nephrostolithotomy, the size of the calculi is the most important indicator for the CPT^® code reported. It is important that the operative report documents the size of the calculi removed in order to make the appropriate selection from the following codes:

• 50080 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting or basket extraction; up to 2 cm
• 50081 over 2 cm

As the descriptor indicates, the dilation, endoscopy, lithotripsy, stenting or basket extraction is included in this code and cannot be billed separately.

When the nephrostomy tract is established, bill CPT^® code 50395 Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous in conjunction with the 50080/50081 CPT^® codes.

If radiological supervision and interpretation are documented by a separate report, then bill the appropriate radiological CPT^® code (e.g., 76000, 74475, 74480, 74485) with a -26 modifier for professional services.

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Urological Surgery Procedures

Q. A cystectomy and continent diversion was performed on a male patient and two surgeons were involved. The first surgeon did the cystectomy and the second surgeon did the diversion. How should each code be billed?

A. Both surgeons should use the CPT^® code 51596, Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder, with modifier -62, Two Surgeons.

There are times when two different surgeons are needed because of their skills to perform different parts of a procedure included in one CPT^® code. It is imperative that the billing offices of both surgeons understand that the same CPT^® code with modifier -62, Two Surgeons, must be billed from each office. Medicare pays 125 percent of the fee schedule, which is then split equally between the two surgeons. Documentation for medical necessity should be submitted in addition to an operative report, which clearly indicates the procedure(s) performed by each surgeon.

If additional procedure(s), including add-on procedure(s), are performed by either surgeon during the same surgical session, separate code(s) can be reported without modifier -62.

Revised! (8/06)
Q. How do I bill for implantation of urethral bulking agents for urinary incontinence?

A. There are presently two types of implant material, collagen and synthetic bulking agents, and the billing of this procedure depends on the material used as the bulking agent.

Collagen

This implant uses collagen as a bulking agent. The FDA requires a skin test 30 days prior to the endoscopic injection of the Contigen^® implant to make sure the patient has no allergic reaction to the collagen. To bill for the skin testing, use CPT^® code 95028, Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify number of tests. As of January 2004, HCPCS code Q3031 collagen skin test was developed to capture documentation that the skin test was performed. This code is bundled into CPT^® 95028 intracutaneous test and is not reimbursed separately.

Do not use HCPCS code G0025, Collagen Skin Test Kit which was deleted in 2002. C.R. Bard, supplier of Contigen^®, will supply the test kit free-of-charge to physicians and hospitals. Contact your Bard representative for details.

The day of the implant procedure, bill the following CPT^® and HCPCS codes:

51715, Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck

L8603, Collagen implant, urinary tract, per 2.5 cc syringe includes necessary supplies

Here are some ICD-9 diagnostic codes that might warrant the collagen implant:

• 596.8 Other specified disorders of the bladder
• 625.6 Stress incontinence, female
• 753.9 Unspecified anomaly of urinary system
• 788.32 Stress incontinence, male
• 788.33 Mixed incontinence, (male or female) urge and stress
• 867.0 Injury to bladder and urethra, without mention of open wound into cavity
• 867.1 Injury to bladder and urethra, with open wound into cavity
• V15.2 Other personal history presenting hazards to health, surgery to other major organs
• V15.3 Irradiation, previous exposure to therapeutic or other ionizing radiation

Synthetic bulking agents

This implant is comprised of synthetic material, which is injected cystoscopically through the urethra into the bladder neck. A skin test is not required before using this product.

The day of the implant procedure, bill the following CPT^® and HCPCS codes:

51715 Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck

L8606 Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies

(This code is not limited only to Durasphere^® and Tegress^®. Should another manufacturer develop a similar synthetic product, this would be the appropriate HCPCS code to use.)

Here are some ICD-9-CM diagnosis codes that may be appropriate for the injection of a synthetic bulking agent.

599.82 Intrinsic urethral sphincter deficiency

625.6 Stress Incontinence, female

788.32 Stress Incontinence, male

Check with local carriers for any Local Medical Review Policies for treatment and coverage limitations on either of these incontinence treatments.

Q. I performed an ESWL on a patient for the destruction of several stones. Can I bill separately for each stone?

A. No. ESWL (as well as the other stone removal codes) is valued to accommodate multiple stone removals in the kidney during a single operative session. However, if you perform an ESWL on both the right and left sides of the kidney and the machine must be repositioned to access the stones, you may bill an ESWL with modifier -50, Bilateral Procedure. Usually, if the claim is submitted with an explanatory cover letter and operative notes, the insurance carrier will reimburse for the bilateral ESWL's.

Q. How do we bill for a urethrolysis?

A. In the past, offices have been advised to use CPT^® code 53899, Unlisted procedure, urinary system, for a urethrolysis. As of January 1, 2004, there is a new CPT^® code for urethrolysis performed transvaginally; CPT^® code 53500, Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (e.g., postsurgical obstruction, scarring). This code describes the procedure performed through a vaginal incision and involves dissection, lysis and removal of periurethral scar tissue and mobilization of the urethra away from the surrounding fibrous tissue resulting from a previous urethral suspension procedure. For a urethrolysis by retropubic approach, continue to use CPT^® code 53899. If the urethrolysis is performed during a removal or revision of a sling for stress incontinence (CPT^® code 57287), it is included in the sling procedure. If a urethrolysis is performed in conjunction with a repeat Marshall-Marchetti procedure, use CPT^® code 51841, Anterior vesicourethropexy, or urethropexy (e.g., Marshall-Marchetti-Krantz, Burch); complicated (secondary repair). The urethrolysis is included.

Q. There is a new procedure for urinary stress incontinence for females using radiofrequency to perform a bladder neck suspension. How do I code for this?

A. At this time, there is no CPT^® code for this procedure. It is recommended that you use CPT^® code 53899, Unlisted procedure, urinary system. When a request for further documentation to support the billing of the unlisted code, use this information when you send your cover letter for this claim. Make sure you equate the procedure to CPT^® code 51845, Abdomino-vaginal vesical neck suspension, with or without endoscopic control (e.g., Stamey, Raz, modified Pereyra) and bill the amount associated with the CPT^® code 51845. If you are performing a laparoscopic sling procedure using radiofrequency, equate CPT^® code 53899 to CPT^® code 51990, Laparoscopy, surgical; urethral suspension for stress incontinence.

Commercial carriers may have a specific procedure to follow when billing unlisted procedures.

Q. My urologist performs a vasectomy using the Vasclip^®. What is the appropriate CPT^® code and can I bill separately for the Vasclip^®?

A. Although there is no cutting of the vas deferens in this vasectomy, the end result is the same: the blockage of sperm to prevent impregnation. The appropriate code for this procedure is CPT^® code 55250, Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s).

The Vasclip^® is not included in the practice expense portion of CPT^® code 55250. The issue is whether or not the physician will be reimbursed for the Vasclip^® or if the patient can be billed for this device. The manufacturer of the Vasclip^® states that some insurance companies (approximately eleven) are reimbursing for the clip. They are also recommending that the clip be billed as a separate supply (along with the invoice with purchase cost of the clip) for reimbursement. However, at this time, there is limited reimbursement. This issue should be discussed with the patient as to payment options. The patient should obtain prior approval by the insurance company for reimbursement. If the clip is not a covered expense for the procedure, check with the insurance company whether or not the patient can be billed for the cost of the Vasclip^®. If the insurance company will allow the patient to pay for the Vasclip^®, have the patient sign a waiver of liability agreement and collect the payment upfront. It is important to contact the insurance carrier to determine what their coverage will be on the vasectomy procedure using the Vasclip^® before the surgery is performed.

Q. How do I bill for a transurethral incision of the bladder neck?

A. There are two options for this type of procedure depending on the equipment used to make the incision. If the urologist uses a resectoscope to make the incision (resect tissue), then use CPT^® code 52500, Transurethral resection of bladder neck (separate procedure). If a knife is used to perform the incision in the bladder neck, use CPT^® code 52276, Cytourethroscopy with direct vision internal urethrotomy.

Revised! (8/06)
Q. What is the best way to bill for a procedure when there is not an appropriate CPT^® code available?

A. You must use an appropriate unlisted laparoscopic or urological procedure code and equate the procedure to another urological procedure that incorporates the same amount of time, skill and work to complete.

In CPT^®'s urology section, these are the available unlisted procedure codes:

• 51999, Unlisted laparoscopy procedure, bladder
• 50549, Unlisted laparoscopy procedure, renal
• 50949, Unlisted laparoscopy procedure, ureter
• 53899, Unlisted procedure, urinary system
• 55899, Unlisted procedure, male genital system

Since Medicare will not allow paper claims unless strict requirements are met, all claims must be submitted electronically and a request for further documentation will be sent to offices to support the billing of unlisted codes.

When a request for documentation has been received, use the following guidelines when submitting a claim where there is no specific CPT^® code to describe the procedure: