Q.
This is a follow-up to a question in your September 2005 “Coding Q&A” column. If you check the CCI edits, there is no way a modifier can be used with 52005 and services provided by code combinations cannot be paid separately. Please help me understand this scenario.
A.
For a review of the original article describing this scenario, please see http://www.urologytimes.com/code52005
The CCI edits reflect the way the Medicare computer has been programmed and the way you will be paid when you submit your claim. However, if there is another rule that states that you should be paid, such as, “If a diagnostic test (the retrograde) leads to the decision to provide a therapeutic procedure, such as the insertion of a stent, breaking up a stone, etc., then the diagnostic retrograde should be paid separately.” As mentioned, you will be denied by the computer, but with an appeal and the proper documentation, you should be paid.
Another scenario that should generate payment for a procedure listed by the CCI as “cannot be unbundled with a modifier” would be a cystoscopy performed in the office in the morning leading to the transurethral resection of a bladder tumor in the afternoon. Because the cysto was performed at a different patient encounter, it should be paid in addition to the TUR of bladder tumor. However, the Medicare computers only detect a calendar day and cannot tell from your form that it may have been at a different patient encounter. The -58 modifiers would give notice, and the appeal with the proper documentation should “educate them.”
Q.
I work in a urogynecology practice, and my physicians are billing for a diagnostic cysto at the same time as a transvaginal tape procedure for stress urinary incontinence. They are billing the TVT procedure and then, following this procedure, they are billing for the cystourethro-scopy with the diagnosis of urgency and frequency. Medicare is denying all of these claims, and we are starting to see denials from other carriers as well. Any suggestions?
A.
The cystoscopy is bundled into the TVT (57288: sling operation for stress incontinence, such as fascia or synthetic). If the cystoscopy is being done to check the anatomy prior, during, or after the procedure to be sure everything is as suspected or to make sure there are no sutures in the urethra, then the cysto is being done to facilitate the procedure and should not be charged.
Medicare has assumed that all your diagnostic studies have been performed prior to you subjecting the patient to a surgical procedure such as the sling placement.
However, if you are performing a diagnostic cysto for a totally different reason, such as surveillance in a patient with a history of bladder tumors, then you should charge the cysto with the -59 modifier and appeal once you have been denied payment. Again, once you provide the information to Medicare that indicates this was a diagnostic procedure performed for a totally different reason, it should be paid.
Q.
My physician attended a seminar and was told we could bill a photoselective vaporization of the prostate, 52647/52648, with instillation of Novocain in the bladder, 51700, and pudendal nerve block, 64430. According to CCI edits, 51700 is incident to 52647 or 52648. What are your suggestions for this?
A.
The local anesthetic is included in the CPT “package” for a procedure. Medicare has adopted this concept. The local instillation of procaine hydrochloride (Novocain) into the bladder area would be considered a part of the procedure, and the instillation procedure should not be charged separately. A regional anesthetic is paid separately in some cases. If your physician is truly doing a pudendal nerve block, then there is an argument for charging the 64430 separately and, if charged, you should be paid.
Medicare has made the decision that you should not charge separately for the nerve block code in addition to a prostate needle biopsy. Also, in your CCI edits, CMS has bundled a number of injection codes into the procedure, most of which are ridiculous. However, CMS does not have the 64430 bundled.
The AUA coding committee has discussed the nerve block for anesthetic of the prostate. Most believe that the physicians are infiltrating the space around the prostate rather than doing a true nerve block and, if that is the case, it should not be charged. The code can only be charged if you are doing a nerve block as defined by the code.
Q.
There are two codes for vasectomy: 55250 and 55450. What are the differences, and when should each one be applied?
A.
Code 55250 is listed under the heading “excision.” However, it does not specifically state that a segment of vas must be removed. It includes the check for sperm samples postoperatively and should be used for the routine vasectomy performed to sterilize.
Code 55450 is limited to a “percutaneous” ligation of the vas and does not include the post-op sperm analysis.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
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.
