PRACTICE RESOURCES > Coding and Reimbursement > Coding Tips > Questions and Answers > Urological Surgery Procedures

Urological Surgery 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.

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.

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. 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.

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

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.)

The ICD-9-CM diagnosis code that may be appropriate for the injection of a synthetic bulking agent is

599.82 Intrinsic urethral sphincter deficiency.

Check with payers for updated payment policies for treatment and coverage limitations on either of these incontinence treatments.

Q.Where can I get a complete list of the CPT® global periods?

A.There are different options for obtaining a comprehensive list of the surgical global periods for all CPT® procedures: 1) visit CMS's web site and download the Physician Fee Schedule for the current year; 2) purchase a resource manual from a publishing house or 3) AUA Coding Today is AUA's on-line product that offers CPT® and ICD-9 information, global periods, plus information on regional fees, CCI and bundling.

Q.Our urologist had to convert a laparoscopic procedure to an open procedure due to complications. How do we bill this?

A.Under Medicare if a laparoscopic procedure is converted to an open procedure, you may only bill the open procedure. Some commercial carriers will allow billing of the laparoscopic procedure with modifier -52, Reduced Services, or -53, Discontinued Procedure, plus the open procedure code.  Use ICD-9_CM code V64.41, Laparoscopic surgical procedure converted to open procedure that should be used as a secondary diagnosis code.

Q.How do I bill for the implantation of fiduciary markers in the prostate for radiation therapy guidance?

A.The codes that are typically used to bill these services are as follows:

55876 Placement of interstitial device(s) for radiation therapy guidance (e.g., fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple
55876 Tissue marker, implantable, any type, each (purchased by your practice)
76942 Ultrasound guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation
or
77002
Fluoroscopic guidance for needle placement (eg biopsy, aspiration, injection, localization device). Note: Some carriers may bundle the fluoroscopic guidance with the 55876.


Q.Is there a CPT® code available to bill for a Martius flap in conjunction with a urethrovaginal fistula?

A.Use CPT® code 57311 Closure of urethrovaginal fistula with bulbocavernosus transplant. Append the 52 modifier since bulbocavernosus transplant was not performed.

If a repair of a vesicovaginal fistula w/flap is performed, use 57320 Closure of vesicovaginal fistula, vaginal approach and 20926 Tissue grafts, other (e.g. paratenon, fat, dermis) for flap harvesting.

Q.How do I bill for ablation of renal tumor(s)? Can I bill for each tumor ablated?

A.There are several codes for ablation of renal tumors. Bill for the appropriate method of ablation.

50250 Ablation, 1 or more renal mass lesion(s),  cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed.
50592 Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency
50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy

According to the descriptor for each code the tumor has an additional parenthetical(s), which means one or more than one. Because of this parenthetical, each of these codes can be billed only once no matter how many tumors are removed from the kidney. However, if you perform this surgery bilaterally, append the 50 modifier.

Please note that neither 50592 nor 50593 include image guidance and monitoring. If performed and documented, the imaging guidance and monitoring should be additionally reported with 76362, 76394 and 76940 depending on the type of guidance. CPT® 50250 cannot be billed with an additional ultrasound code.

Q.A patient who had a cystectomy with ileal conduit is now having problems, which require the physician to visualize the conduit. Is there a code for an endoscopy through a stoma into the ileal loop?

A.Yes, use CPT® Code 44380 Ileoscopy, through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) for the visualization of the conduit.

Q.If a radical cystectomy is performed and the prostate or uterus is removed in the same session are they coded separately?

A.In males, when a radical prostatectomy is performed in addition to radical cystectomy during the same operative session, both procedures may be billed. The CPT® code 55840 "prostatectomy; retropubic radical, with or without nerve sparing" can be billed with a -51 modifier in addition to the appropriate cystectomy code.

In females, when a removal of uterus and/or tubes and ovaries is performed in addition to the radical cystectomy, CPT® code 58150 “total abdominal hysterectomy (corpus and cervix) with or without removal of tube(s), with or without removal of ovarie(s)” with a -51 modifier may be billed in addition to the cystectomy code.

Use one of the appropriate CPT® codes from the following list of cystectomy procedures as the primary procedure:

51570 Cystectomy, complete; (separate procedure)
51575 with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes
51580 Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations:
51585 with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes
51590 Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including bowel anastomosis;
51595 with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes
51596 Cystectomy, complete, with continent diversion, any technique, using any segment of small and/or large intestine to construct neobladder

Q.Another patient had a cystectomy with a continent diversion. How do I bill for an endoscopy into the pouch?

A.Use CPT® code:

44385 Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).

Q.How do I bill for stent insertion in either an ileal conduit or a continent diversion?

A.Use CPT® code 44383 Ileoscopy, through stoma; with transendoscopic stent placement (includes predilation) for the ileal conduit. For stent insertion into a continent diversion, use CPT® code 44385 Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) with a 22 modifier since there is no specific CPT® code for the stent insertion in this situation.

Q.How do I bill for the revision of the stoma? The patient had a prior ileal conduit and the stoma is starting to close.

A.Use CPT® Code 44312, Revision of ileostomy; simple (release of superficial scar) (separate procedure) or 44314, Revision of ileostomy; complicated (reconstruction in-depth) (separate procedure). Use the 44314 if a revision of the ileal conduit must be performed at a later date.

Q.Can I charge for supplies used during surgical procedures in my office (eg, biopsy needles, catheters)?

A.When a CPT® code is established, there are three components: the physician's work, malpractice and practice expense. These components are then added together to establish the relative work values or the amount you can be reimbursed for the procedure. The practice expense portion of the RVU includes all the supplies necessary to perform the procedure and the equipment necessary to perform the procedure. Generally, you cannot bill the use of supplies for the performance of surgical procedures.

Exceptions would be explained in CPT descriptions (eg. 55876)

Q.How do I code for minimally invasive prostate procedures?

A.Use one of the appropriate CPT® codes from the following list:

52647 Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral caliberation and/or dilation, and internal urethrotomy are included if performed)
52648 Laser vaporization or prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral caliberation and/or dilation, and internal urethrotomy are included if performed)
52649 Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral caliberation and/or dilation, and internal urethrotomy are included if performed)

Q.There are several different diagnosis codes for BPH. What is the difference between hypertrophy and hyperplasia?

A.The BPH diagnosis codes are:

600.00 Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract (LUTS)e
600.01 Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)
600.20 Benign localized hyperplasia of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS)
600.21 Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)
600.90 Hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary symptoms (LUTS)
600.91 Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (LUTS)

Hyperplasia is excessive proliferation of normal cells in the normal tissue arrangement of an organ.

Hypertrophy is an increase in the size of an organ or structure. Either way, the prostate size is increased which could cause urinary complications. According to the NCHS, the two hyperplasia codes and the one hypertrophy code can be used interchangeably. NCHS advises the use of the diagnosis code that fits the terminology the physician uses.

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