Q:
One of our urologists performed a radical cystectomy with continent diversion and a lymphadenectomy on a “Mr. Smith.” How do I charge? I cannot find the code for a radical cystectomy.
A:
There is no code for a radical cystectomy. You will have to use the code for a “total” cystectomy. If you look at the 5159X series of codes, you will find a code for a complete cystectomy with continent diversion. Since you indicated that your doctor performed a cystectomy with continent diversion, the CPT code that you should use is 51596 (Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder), as it explains both parts of the procedures performed.
As you can see by looking at code 51596, the description does not include the lymphadenectomy, and a further search of codes in this area does not include a code with cystectomy, continent diversion, and a lymphadenectomy. Therefore, you should charge for the lymphadenectomy separately.
There are two codes that could be used to report the lymphadenectomy, depending upon the extent of the node dissection: 38770 (Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes) or 38780 (Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes). If the lymphadenectomy performed was more extensive than 38770 but less than 38780, you could charge 38780–52, indicating that 38780 was the most appropriate code, but a less extensive resection was performed. Your doctor can identify the appropriate code for you. If the lymphadenectomy was bilateral, you would need to also add the –50 modifier to the chosen code.
Because “Mr. Smith” is a man, the doctor probably removed his prostate (often the case with a radical cystectomy). If the prostate was removed along with the bladder and this was appropriately recorded in the operative note, then it would be appropriate to charge for a prostatectomy as well: 55840 (Prostatectomy, retropubic radical, with or without nerve sparing). If the node dissection performed is equivalent to the lymphadenectomy included in the prostatectomy description of code 55845 (Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes), the proper reporting of the service would be 51596 and 55845 only; the lymphadenectomy code would not be separately charged.
Q:
We have had difficulty with reimbursement from CMS for DEXA scans in hypogonadal men. There is ample literature attesting to the accelerated bone loss in hypogonadal men and use of DEXA scans to assess for osteoporosis. However, when we order a DEXA scan with the code for hypogonadism (testicular failure), 257.2, CMS refuses to pay. Also, there seems to be an acceptable code for bilateral orchiectomy in men: V45.77 (acquired absence of the genital organs).
I assume this represents outdated thinking by CMS that osteoporosis is a disease of women only, and that they are unaware of newer data and recommendations on the evaluation of hypogonadism. Is there any way to educate CMS on this issue?
A:
The answer is somewhat complicated, as there are both screening services under dual-energy x-ray absorptiometry (DEXA) scans as well as medically necessary services that can be covered. The coverage under Medicare is restricted, which is addressed in Title IV of the Balanced Budget Act (BBA) of 1997, Section 4106. This section includes language providing for Medicare coverage of bone mass measurements and coverage of FDA-approved bone mass measurement techniques and equipment for “qualified” individuals. These procedures are only covered when medically necessary.
Each carrier has some flexibility in determining what “medically necessary” entails. Currently, almost all carrier coverage indications are the same, limiting coverage every 2 years for medically necessary screening (primarily of postmenopausal women with other risk factors). However, carriers can allow more frequent services if medically necessary.
Your best approach at this time would be to provide clear medical literature support when approaching the carrier medical director through your Carrier Advisory Committee representative. However, given the current coverage coherence among carriers and the national payment directive in the BBA, support from medical literature would have to be very strong to change a policy.
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.
