Billing is not possible if performed within global of related procedure
Q:
I was hoping you could clear up an issue for us. When I give a patient a voiding trial with a “fill and pull,” where I fill the bladder with water and pull out the catheter, can I code for a “bladder instillation?” Some of us say no; however, others say we are clearly putting something into the bladder. I would sincerely appreciate your opinion.
A:
If you insert a fluid into the bladder, (contrast, medication, saline, etc.), the procedure qualifies for the code 51700 (bladder irrigation, simple, lavage, and/or instillation). The big question is: Can you charge for it? If you are in the global of a “related” procedure; eg, during the first 90 postoperative days of a radical prostatectomy, the answer is no. It is clearly related and will be denied. There is no modifier that should be used to remove it from the global.
However, if not in a related global, then you should charge. An example would be if a patient developed retention after a transurethral resection of a bladder tumor, a catheter is inserted, and is now being removed 1 day later (outside the Medicare global).
The other issue is medical necessity, which underlies the appropriateness of billing services provided to all patients. Make certain that the instillation is required for the patient’s condition and performance of the service is clearly documented.
Q:
We are introducing the treatment of kidney stones with extracorporeal shock wave lithotripsy in the physician office (anesthesia free) and would like to secure reimbursement rates close to the ones available for hospitals and surgery centers. What should be our strategy?
A:
The short answer: Negotiate good contracts with private payers. Medicare’s payment for physician offices is set. That payment is lower than payment to hospitals, and is not subject to negotiation. However, you can negotiate a “carve-out” for all private payers. We think the best strategy is to research the charges by the hospitals and other freestanding units that use the hospital outpatient payment system and negotiate a fair price that will save the insurance company money. Obviously, you would like to be paid well for the procedure. There should be plenty of room between your cost and the cost to the insurance company for the procedures performed at the hospital to negotiate a fair savings to the insurance company and a good return for you. Good luck.
Q:
I am a certified coder for an ambulatory surgery center. I have recently had questions regarding CPT 52005. The CMS edits bundle this code with CPT codes 52204 and 52214 but allow for a modifier if documentation supports it. I know that just because edits allow for a modifier doesn’t mean you can always unbundle. Can you offer some insight into when and if you can ever unbundle CPT 52005? An example: Recently, the urologist performed a cystoscopy with bilateral retrogrades and also fulgerated polyps of the prostate.
A:
Code 52005 (cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) specifically includes ureteral catheterization. The codes 52204 (cystourethroscopy, with biopsy) and 52214 cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral gland) are procedures performed in the bladder/urethra. Ureteral catheterization is not usually required in performance of these services. Therefore, if performed for another reason, 52005 should be charged with the –59 modifier. However, if necessary to perform a retrograde to rule out ureteral injury from the fulguration, do not charge. In addition, 52005 must be medically necessary, and documentation must justify the service.
Here is an example of when not to unbundle a retrograde: 52354 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion). If this service does require a retrograde to assist in the procedure in any way, you should not charge. In that example, 52005 would not be appropriate in addition to the 52354.
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.
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.
