Q.Is CPT® code 76000, Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (e.g., cardiac fluoroscopy) inherent in CPT® code 50590, Lithotripsy, extracorporeal shock wave?
A.Yes, according to CCI edits version 9.2, which went into effect July 1, 2003, fluoroscopy has been bundled into ESWL. This means for Medicare claims, modifier -59 Distinct procedural service must be appended to code 76000 to receive reimbursement. There must be a medically necessary reason for the use of fluoroscopy apart from locating the stone for the lithotripsy.
Q.My urologist performs retrograde pyelograms CPT® code 52005 in conjunction with many cysto/ureteroscopy procedures. Can I bill separately for the retrogrades?
A.According to the CCI edits, retrograde pyelograms are bundled into cystoscopy codes 52320 through 52355 and cannot be unbundled under any circumstances. If the retrograde is performed to complete the procedure, CCI considers the retrograde inherent to the endoscopy procedure performed. However, if the physician performed the supervision and interpretation of the retrograde, the urologist may bill the 74420 urography, retrograde, with or without KUB. If the physician does not own the equipment, a -26 modifier must be appended to the 74420. A separate paragraph must be dictated with findings.
Q.Is a separate report required for diagnostic testing (such as transrectal ultrasound, renal ultrasound, post-void residual)?
A.Yes, all CPT® services (E&M, procedures and radiology) must be documented. The American Medical Association clarified this issue in the E&M Services Guidelines Section in the CPT® book. The language reads:
“The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E&M services. Physician performance of diagnostic test/studies for which specific CPT® codes are available may be reported separately, in addition to the appropriate E&M code. This physician interpretation of the results of diagnostic tests/studies with preparation of a separate, distinctly identifiable signed written report may also be reported separately, using the appropriate CPT® code with the modifier -26, Professional Component, appended.”
However, many insurance companies, including Medicare, will not pay for both the radiologist's interpretation of a diagnostic study and for the physician who reads and interprets the results of a diagnostic test performed outside the physician's office. If the physician performs the procedure and interprets the result, coordinate billing on this with the hospital. The hospital should bill for the technical component (-TC) and the physician should bill for the professional component (-26).
If the tests/studies are performed in the physician's office, bill the CPT® code for the actual test. No modifiers breaking out the technical and professional components are necessary. A separate written report is required for the patient's chart.
Q.If an ultrasound is performed on a male, what must be evaluated for it to be considered a complete study?
A.In order to bill a 76856 Ultrasound pelvic (nonobstetric), B-scan and/or real time with image documentation; complete evaluation & measurement (when applicable) of the urinary bladder, evaluation of prostate and seminal vesicles (visualized transabdominally), and any pelvic pathology (bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess) must be performed and documented.
Q.Can I bill for both an abdominal ultrasound and pelvic ultrasound if the urologist evaluates the kidneys and bladder?
A.You cannot bill for both a 76705 Ultrasound abdominal, B-scan and/or real time with image documentation; limited (e.g., single organ, quadrant, follow-up) and a 76857 Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation, limited or follow-up (eg, for follicles) when each of these organs is evaluated. CPT® code 76770 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), B-scan and/or real time with image documentation, complete should be billed if the clinical history suggests urinary tract pathology, and evaluation of both kidneys & bladder.
Q.How do I code for a dual energy X-ray absorptiometry (Dexa) scan and will it be covered?
A.Dual energy X-ray (DXA) absorptiometry is a means of measuring bone mineral density. It is used to diagnosis osteopenia or osteoporosis. DXA is also effective in tracking the effects of treatment for osteoporosis and other conditions that cause bone loss. In urology, many physicians will recommend that prostate cancer patients receiving androgen deprivation therapy have a DXA scan.
For many third-party payers, there are policy limits in place that restrict the frequency of DXA scans on an individual. The same is true for Medicare. Medicare has established a national coverage determination (NCD) for bone density study procedures that address the type of procedures covered, qualified individuals, provider requirements and frequency limitations. Medicare carriers may or may not have a written local coverage determination (LCD) and/or articles outlining additional coding guidelines particularly for patients not addressed in the NCD. Claims will be denied if the medical policy limits have already been met. If the service requires additional study beyond these limits and you believe the study is medically necessary you should contact the payer to discuss the case prior to rendering the service.
|DXA, Bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) – use CPT code 77080.|
|DXA, Bone density study, 1 or more sites; appendicular skeleton, (peripheral) (e.g., radius, wrist, heel) – use CPT code 77081.|
|DXA, Bone density study, 1 or more sites; vertebral fracture assessment – use CPT code 77082.|
For first-time screenings, your patient may or may not be covered by their insurance carrier. Depending on the patient’s diagnosis, you may have to have them sign an Advance Beneficiary Notice (ABN) form, unless the scan shows osteoporosis in which case that is the diagnosis to use and is a covered diagnosis by Medicare. If a repeated scan is not positive for osteoporosis, then any repeats are still considered screens and the patient continues to be responsible if they signed an ABN.
Diagnosis codes that support medical necessity can and do vary by payer; therefore, it is important to contact your local payers for coverage and coding guidelines to ensure accurate billing.
Please be sure to check your carrier’s LCD list to see in fact what diagnosis codes are or are not covered by your Medicare carrier. The link to check the NCD/LCD is http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd.