Work directly with your carrier’s medical director to determine the proper way to bill.
Q
Can I be reimbursed for in-office injection of botulinum toxin in patients with refractory overactive bladder?
A
Since botulinum toxin does not have a CPT code and has not been approved for payment, you will have to work directly with the Medicare carrier medical director to determine the proper way to bill and to determine if the carrier will pay. Medicare does not make pre-determinations on payment. Botulinum toxin is not FDA approved for this indication, making payment more difficult.
One Medicare carrier medical director indicated that he would like to have the procedure presented as an unlisted procedure with the appropriate diagnosis. You should send the necessary information that will allow Medicare to understand the work involved by suggesting a comparable procedure and any information that suggests the efficacy of treatment.
Medicare has the option of denying payment or setting up payment for the unlisted procedure with that particular diagnoses at their determined payment schedule.
Q
For codes 53600-53621, our physician is charging a fee for radiologic supervision and interpretation and is getting denied by Medicare. Is this bundled with those codes, or does it need a modifier?
A
In order to charge for radiologic supervision, one must have performed a radiologic procedure. I’m unaware of the procedures associated with these codes.
If the physician performed a urethrogram or some other procedure, he should be able to provide and charge for radiologic supervision and interpretation.
Q
We are using an ultrasound machine with true ultrasound imaging documentation. For private insurance, we bill CPT-4 Code 76857 for the residual urine. Can we use the same code for Medicare instead of 76775 that has “limit utilization?”
A
The 76857, retroperitoneal non-obstetrical limited, and 76775, abdominal retroperitoneal limited, are both technically correct for use when you are doing an ultrasound of the bladder. The bladder is a retroperitoneal organ and a pelvic non-obstetrical organ, and it is appropriate to use either code depending on the payer and its preferences.
According to current CPT rules, either of these codes would be correct in reporting an imaging ultrasound for residual urine. However, at the AUA annual meeting in April, the Coding and Reimbursement Committee determined that the proper code to report an ultrasound for residual would be 51798. The committee suggested this code should be used for Medicare, as well as private payers, even if you are using an imaging machine.
Q
Our physician is performing a cystoscopy with hydrodistension (52260) and clearly dictating in his note that he is removing the scope and performing wide caliber urethral dilation with Hagar dilators. He feels he should be able to bill 52260 and 52281. I understand the correct codes to be 52260 and 53665. These two codes are mutually exclusive, so I think he would only be able to bill the 52260. On the other hand, he thinks that, if the scope is used originally, all the following care should fall into the cystoscopy procedures. Please advise.
A
First and foremost, 52260 and 52281 are not mutually exclusive and can be billed together. That is the good news. The bad news is that Medicare does not pay 50% of the second procedure. They subtract the price of the cystoscopy and pay you the difference.
Also, you need to be sure that you are charging the correct codes. The 52260 is for cystourethroscopy, with dilation of bladder for interstitial cystitis, general or conduction (spinal) anesthesia. The 52265 is for cystourethroscopy, with dilation of bladder for interstitial cystitis, local anesthesia. The 52281 is for cystoscopy with dilation of a urethral structure.
If the physician performed a urethral dilatation for urethral syndrome, 52285 would be the correct code.
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.
