Q.
A urologist sees a patient and bills a consult. As a result of that visit, he decides the patient should have a procedure and schedules the procedure for the following week. The patient returns in a week, and prior to the procedure, the provider prescribes antibiotics and discusses the procedure and meds with the patient and her daughter. The provider spends 15 minutes counseling the patient and the daughter, and thus wants to bill for an E&M as well as for the procedure he performed. Since the patient came in strictly for the procedure, can the physician bill for an additional E&M charge? Also, please indicate how the counseling should be documented.
A.
If, as stated in the question, a previously scheduled procedure is discussed and a prescription of antibiotics related to procedure care (eg, prevention of infection) is provided during the global period, then the visit should not be billed separately. If discussion is about the further treatment of a disease process, eg, the prescription of antibiotics for treatment of a chronic infection, it should be billed with modifier –25 if properly documented.
The total time documented should include overall E&M time spent separate from the procedure and should exclude time spent in counseling related to the procedure or to the findings/results of the procedure and items discussed.
In addition to the time documented, the separate note for the E&M service should include the items included in the discussion.
Q.
What CPT code would you suggest I use for a cystoscopy with botulinum toxin A (Botox) injection?
A.
Use unlisted code 53899 for this service. As with any unlisted code, documentation will need to be included with each service billed until the payer establishes a policy. Some physicians have had success writing to the medical director and requesting a payment policy for this service. Make sure that you include supporting clinical documentation for any payment policy.
Q.
I have been using the unlisted procedure code of 53899 as well as the ultrasound guidance code for placing gold tumor marker seeds for radiation therapy for prostate cancer. Has a specific code been established for this procedure? It would certainly reduce the hassle of Medicare rebilling and explanations.
A.
Unfortunately, no code has been established for the placement of gold seed tumor markers.
For prostate cancer, we recommend using code 55899 instead of code 53899 in addition to the ultrasound guidance (76950). Both –99 codes are unlisted procedures, but code 55899 is more correct from an anatomical sense. Also check with your carrier regarding payment policy for this service. Some Medicare carriers are publishing payment policies (local coverage determinations) for these services.
Q.
I have been having problems with reimbursement for a cystoscopy done at the time of prostate biopsy. So far, it has not been a problem with our Medicare carrier, but several private insurers, as well as United Mine Workers Medicare, have been saying it is included in the biopsy procedure. Any suggestions on how to bill this, rather than making the patient come to the office or outpatient surgery facility on separate days for the unrelated procedures?
A.
You should be paid for both services. Use separate diagnoses if applicable and appeal all denials. For those payers that are denying the cystoscopy at the time of biopsy, you may also try billing the 52000 with modifier –59, even though it is not required for Medicare.
In your appeal of denials, include information regarding the savings to the insurance company and the patient in terms of both cost and convenience, in addition to the medical necessity included in your note.
Q.
I recently performed a cystotomy with removal of a bladder suture from a previously attempted bladder suspension. I tried to remove the suture transurethrally, but could not. I cannot find a procedure code for a cystotomy with removal of foreign body. Any suggestions?
A
Lacking a CPT code or level II HCPCS code for the services provided, you have two alternatives for the service provided. You could report the service using code 51065–22 or –52 to indicate the service provided is not as the description indicates, and the fee can be either discounted or increased, depending upon the case.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
Mark Painter is CEO of PRS Urology SC in Denver.
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
