Inclusion of relative time reference can help justify charging additional fees for procedures
Q What is the CPT code for cystoscopic urethral realignment with Foley placement post-motorcycle accident?
A We will assume that you are taking a cystoscope through the distal urethra and navigating the remainder of the urethra into the bladder, which is made more difficult by injury to the penis. Once you have determined that the urethra is intact, you are inserting a Foley catheter through the now-straightened urethra. We will also assume that any repairs to the penis, including long-term fixation of the urethra, were made during a separate operating session at a later date. An operative note would be required to provide any additional advice for accurate coding.
Within the parameters of the scenario above, the coding would include only the cystoscopy, with a modifier to indicate unusual circumstances. In this case, use 52000 (cystourethroscopy [separate procedure]) with appended modifier –22. The CPT definition of increased procedural services is as follows: “When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier –22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required). Note: This modifier should not be appended to an evaluation and management (E&M) service.”
Unfortunately, the insertion of a Foley catheter is included in the cystoscopy and cannot be unbundled in most cases. You will need to submit an operative report and adjust your fee accordingly. It is always recommended that, in addition to the clinical circumstances that caused the increased work, you include a relative time reference to justify the additional fee. As an example, indicate that the service required an extra 45 minutes due to the condition of the patient.
One additional charge that may apply would be E&M services. If you clearly document history review, physical examination (likely limited), and medical decision making, an E&M with modifier –25 may be warranted.
Q What are the most appropriate codes to use when coding for a cystectomy/prostatectomy with urinary diversion?
A As you know, there are different cystectomy codes listed in the CPT manual. We will provide the appropriate prostatectomy code with each cystectomy code and the appropriate way to bill for a prostatectomy in conjunction with a cystectomy, as they differ slightly (below):
Select the cystectomy code with the appropriate diversion and lymphadenectomy as listed in the description included in the documentation. In addition, bill the appropriate prostatectomy code. Of note in each of the present coding combinations, with the exception of 51596, the appropriate code is 55840 for the prostatectomy, as the lymph node removal is included in the description of the correct cystectomy code for each technique under most circumstances. Thus, only a cystectomy with continent diversion would be reported with the prostatectomy with nodes (55845). If the description does not adequately describe the lymph nodes removed, you will need to bill the appropriate lymphadenectomy codes and then bill the cystectomy and prostatectomy codes without lymphadenectomy.
Also, none of the code combinations above are bundled under the Correct Coding Initiative; therefore, if you were to add a modifier, you would add modifier –51 to the prostatectomy code, and the lymphadenectomy codes, if they are billed separately.
