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

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. 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.

As of (date) Medicare changed their rules for billing modifier 62 Two surgeons must be from different specialties.

According to Medicare Claims Processing Manual section 40.8.
40.8. - Claims for Co-Surgeons and Team Surgeons
(Rev. 1, 10-01-03)
B3-4828, B3-15046
A. General

Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery.
B. Billing Instructions The following billing procedures apply when billing for a surgical procedure or procedures that required the use of two surgeons or a team of surgeons: If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier “62.” Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements. Documentation of the medical necessity for two surgeons is required for certain services identified in the MFSDB. (See §40.8.C.5.);
If physicians are of the same specialty designation a special report will be required with the initial claim.

Q. What are the CPT code(s) for an open cystoprostatectomy versus a laparoscopic cystoprostatectomy?

A. The CPT code(s) use for the open cystoprostatectomy are 51570 Cystectomy complete (separate procedure) and 55840 Prostatectomy, retropubic radical, with or without nerve sparing. There should be supporting documentation for both procedures.

For the laparoscopic prostatectomy there is only one CPT® code 55866 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed, now for the laparoscopic cystectomy there is no CPT code so we would have to use an unlisted code, 51999 Unlisted laparoscopy procedure, bladder. The unlisted code would need to be equated to a similar CPT code. You may query your physician.

Q. Does insurance cover Macroplastique treatment?

A. Medicare Carriers and most private insurers cover Macroplastique as a urethral bulking treatment for adult females with stress urinary incontinence (SUI) primarily due to intrinsic sphincter deficiency (ISD). It is recommended that you get approval from the patient's insurance company before treatment begins. Medicare does not require prior authorization.

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 covers Macroplastique®, Durasphere®, and Tegress®. Should another manufacturer develop a similar synthetic product, this would be the appropriate HCPCS code to use.)

The ICD-10-CM diagnosis code that may be appropriate for the injection of a synthetic bulking agent is:

N36.42 Intrinsic scphincter deficiency
N39.31 Stress Incontinence, female

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

A. We have provided a list of CPT codes with global periods. This list is for Medicare carriers, Private carriers may have their own set of global periods.

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. There is no ICD-10 code at the present time to use.

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
A4648 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. You would use CPT code 52000 cystourethroscopy.

2016 Editorial revision to guidelines under Endoscopy, Cystoscopy, Urethroscopy, Cystourethroscopy subsection for these procedures.

Because cutaneous urinary diversions utilizing ileum or colon serve as functional replacements of a native bladder, endoscopy of such bowel segments, as well as performance of secondary procedures can be captured by using the cystourethroscopy codes. For example, endoscopy of an ileal loop with removal of ureteral calculus would be coded as cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus (52320).

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. You would bill CPT code 52000 when endoscopy procedure is being done through a pouch.

Guidelines have changed for 2016; Because cutaneous urinary diversions utilizing ileum or colon serve as functional replacements of a native bladder, endoscopy of such bowel segments, as well as performance of secondary procedures can be captured by using the cystourethroscopy codes.

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

A. Use CPT code 52332 Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type).

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 50727 Revision of urinary-cutaneous anastomosis (any type urostomy) or CPT code 50728 Revision of urinary-cutaneous anastomosis (any type urostomy); with repair of fascial defect and hernia. It will all depend on the supporting documentation.

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 example:

Exceptions would be explained in CPT descriptions example:

CPT code 55876 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple

 

(Report supply of device separately)

CPT code 52287 Cystourethroscopy, with injection(s) for chemodenervation of the bladder

(The supply of the chemodenervation agent is reported separately)

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

A. BPH diagnosis codes are:

N40.0 Enlarged prostate without lower urinary tract symptoms
N40.0 Enlarged prostate without lower urinary tract symptoms
N40.1 Enlarged prostate with lower urinary tract symptoms
  Use additional code for associated symptoms when specified:
N40.2 Nodular prostate without lower urinary tract symptoms
N40.3 Nodular prostate with lower urinary tract symptoms

Q.How do you bill for a hand-assisted laparoscopy procedure?

A.There is no special code for hand-assisted laparoscopy procedures. Use the appropriate specific laparoscopy CPT® code for the procedure or the unlisted laparoscopy CPT® codes for the appropriate organ. If there is no unlisted laparoscopy code, use code 53899, Unlisted procedure, urinary system.

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