Q.
Which nerve block code should we be using when we administer it for a prostate ultrasound and needle biopsy—64450 or 64430?
A.
Given current Medicare policy, we do not recommend billing either code in conjunction with prostate biopsy. Code 64430—injection, anesthetic agent; pudendal nerve—with a total RBRVS value of 4.04, is included in code 55700 under the Correct Coding Initiative, but marked as unbundling allowed with modifier. Code 64450—injection, anesthetic agent; other peripheral nerve or branch—with a total RBRVS value of 2.65, is also included in code 55700 under the Correct Coding Initiative, and marked as unbundling allowed with modifier. If both are billed, they would require a modifier –59 with the payment for code 64430 being relatively higher than code 64450.
However, a number of issues must be considered prior to billing a nerve block.
First, the CPT manual specifically states that each CPT surgical code includes “local infiltration, metacarpal/meta-tarsal/digital block or topical anesthesia” and other items related to patient care for the surgical service reported.
Relative to this issue, one must consider if the injection of anesthetic is a local infiltration for the performance of the procedure. If the answer to this question is “yes,” then neither code should be billed. Injection of anesthetic can be considered something other than local infiltration if the anesthetic injection is more appropriately classified as a regional block for the performance of the procedure or is considered as postoperative pain control management.
Second, if the injection of anesthetic is not considered a local infiltration for the performance of the procedure itself, one must decide which code is more appropriate. To code 64430, the pudendal nerve must be located and the injection of the anesthetic into the nerve must be documented. If the anesthetic is not injected into the pudendal nerve, then code 64450 describes the injection of anesthetic into a peripheral nerve or branch, which must also be documented to report this code.
Last, one must consider the billing rules of each payer. The previous considerations are CPT related, and as we all know, CPT is but the foundation for coding rules and regulations. As noted, Medicare considers both injection codes as included in the code 55700, with unbundling or payment allowed only if the definition of modifier –59 (distinct procedure) is met. To use the –59 modifier to remove a service from the bundle of another service, it must be provided during a separate patient encounter, provided at a site that is separate from the service or involve a procedure that is a distinct and separate effort from what is normally provided for the service.
In this scenario, the injection is clearly not provided at a separate patient encounter and is provided in the same anatomic area. Therefore, to meet this definition with Medicare patients, one must determine if the effort is truly separate and distinct from the biopsy. Further, Medicare policy states that payment for anesthesia services other than conscious sedation under certain circumstances, provided by the surgeon, should not be separately paid. Other payers may have implemented different interpretations in this regard. Your contractual agreement, if you have one, will govern whether or not the service should be reported or paid.
Be consistent in implementation of CPT rules for non-contracted payers. Medicare payment policy also indicates that management of postoperative surgical pain is considered part of the global payment package and is not separately payable.
Q.
How are cystoscopic botulinum toxin A (Botox) injections into the bladder billed and reimbursed?
A.
At present, there is not an accurate code available for cystoscopy with injection of botulinum toxin into the bladder. Reporting of this service at present is most accurately reflected with the use of the unlisted urinary code 53899.
Q.
What code should I use to report a complex catheter removal without a reinsertion?
A.
In years past, code 53625 included a reference to complex catheter removal in its parenthetical notation. When CPT eliminated these codes and renumbered the catheter insertions to 51701, 51702, and 51703, all references to removal only were removed. At present, reporting of a complex catheter removal without reinsertion should be covered under the unlisted code 53899 or included in the reporting of an E&M service. If the removal is followed by insertion of a new catheter, parenthetical notation indicates it is appropriate to report code 51703—complex catheter insertion.
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.
