Use -59 modifier when billing for indwelling stent

Q

I am in a multiple-physician urology practice. One of our physicians believes that billing 52332 with 52352 or 52353 with a ­59 modifier should be paid, and that billing 52005 with 52332 with the ­59 modifier should be paid (ie, 52005-59). When is it appropriate to use the ­59 modifier?

A

The physician is correct. Insertion of an indwelling stent (52332) should always be charged in addition to a ureteroscopy (52351-52354) by adding the ­59 modifier.

The retrograde (52005) is a little trickier. If this is a diagnostic retrograde, then it should be charged in addition to the other two codes. However, if the retrograde is done to facilitate the insertion of the wire or the advancing of the ureteroscope, then it should be considered an essential part of the procedure and should not be charged separately. The tricky part is that the Correct Coding Initiative, in the first quarter of 2004, bundled it into the insertion of the stent and by designation, the retrograde cannot be unbundled.

Therefore, if a diagnostic retrograde was performed, I would charge using the ­59 modifier and be prepared for a denial and appeal.

Q

My group would like to buy a CT scanner and have a radiology group read the scans by teleradiology. However, we have been advised that we cannot bill Medicare if the radiologist is not reading the scans on site. We are confused, as we see MRI centers sending their scans to be read by radiologists hundreds of miles away. Can you clarify this paradox?

A

I am not sure I can clarify the paradox because I do not understand the concern about charging for the CT scan in your office.

If you own the equipment, are providing the service, and are contracting with a radiologist for the reading, you should be able to charge for the service. Having said that, you need to check several issues to be sure there are no problems.

Some states may have a rule that telemedicine (reading x-rays, consulting, etc.) must be performed by physicians licensed in that state. In reality, I would bet that you and the other urologist read the CT scan in the course of treating the patient. You are purchasing or contracting for the radiologist to read the scan for quality control and malpractice reasons.

If this is the case, you probably are safe, even if your state has that rule.

Q

In regard to your recent column (“Established patients: How to determine the proper level,” November 2003, page 45), if a patient has stable BPH and his medication (ie, tamsulosin) is continued, would that be considered level two or level three medical decision-making? I understand that over-the-counter drugs are level two, and a new medication or change in the dose because of worsening problems would be considered level four.

A

Your question is hard to answer without seeing your documentation. In reality, it could be either one depending on several factors.

Let me clarify: You do not have to change a dose of medication for it to qualify for moderate (level four) under the risk category of medical decision-making. Prescription drug management should be counted. If you start a medication, make the decision to continue it, change it, or stop it.

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.