2013 AAPC National Conference
Orlando, Florida
April 14 - 17, 2013
Michael A. Ferragamo MD, FACS
Clinical Assistant Professor of Urology
State University of New York
Stony Brook, Long Island, New York
Editor: Urology Coding Alert
Eli Research, Durham, North Carolina
New Coding for 2013
and
The Correction of Common
Coding Problems in Urology
“all rights reserved”
Diagnostic Code Freeze for 2013
ICD-9 Code Changes
International Classification of Diseases
• There will be no new, revised, or deleted
diagnostic codes for 2013
• ICD-10 will start on October 1, 2014
• No new diagnostic code changes until Oct.1, 2015
Urology Coding Update
CPT Changes for 2013
Current Procedural Terminology
Professional Edition
New Botox Coding for Urology
Intramural Bladder Injections
• Botox type A
• 100 to 300 units
• Overactive Bladder
Syndrome
• Recently approved by
the FDA for
neurogenic bladder
ICD-9 596.54
New CPT Code for 2013
• 52287 cystourethroscopy with injection(s)
for chemodenervation of the bladder
– Use for Botox bladder wall injection
– One code for multiple injections
– Zero (0) day global
– Replaces unlisted code 53899 and 64640
– Code (bill) for the chemodenervation
agent, if provided by the physician, (office)
– Botox: J0585 per 1 unit
– No payment for surgical assistant
*2013 CPT Changes, An Insider’s View
Botox Bladder Wall Injections
52287
• Specific urinary diagnoses: ICD-9 codes 596.52, 596.54*
596.55*, 596.59, 599.82, 788.31, 788.33, 788.34*
• Check LCD for each carrier
• WPS and Cahaba (GA) only pays for ICD-9 596.54,
596.55
• Verify Coverage/Payment and obtain Authorization
• Do not administer more often than every 90 days
*Source: June 2010 Medical Practice Coding Pro
52287 Urological Bundling
CCI Version 19.0 for 1/1/13
• Bundled CPT codes: into 52287
– 51701
52310
– 51702
52315
– 51703
53000 to 53025
– 52000
53600 to 53665
– 52001*
* Can unbundle with modifier 59
52287 Urological Bundling
CCI Version 19.0 for 1/1/13
• Non bundled CPT codes:
– 52204 cystourethroscopy and bladder
biopsy or biopsies
– 52214 cystourethroscopy and
fulguration
Botox Bladder Wall Injections
52287 3.20 Work RVUs
Total RVUs 9.16/4.90
• 2013 fee schedule: (conversion factor…$34.0230)
– Unadjusted Medicare fee
• Non facility $311.65
• Facility
$166.71
Botox Bladder Wall Injections
Allergan (100 units…$525.00)
• Coding method: (if box 24G accepts only
two digits)
CPT
52287
J0585
J0585-59
24G
99 units
1 unit
ICD-9
PAID
596.54
596.54
596.54
$311.65
$541.53
$5.47*
$858.65
* 2013 first quarter fee schedule
Botox Bladder Wall Injections
Allergan (100 units…$525.00)
• Coding method: (if box 24G accepts 3
digits)
CPT
52287
J0585
24G
100 units
ICD-9
596.54
596.54
PAID
$311.65
$547.00*
$858.65
* 2013 first quarter fee schedule
Urological Coding Errors
2013 Drug Information Required
• Box # 19 of CMS-1500 or the e-narrative
(EHR)
– Name of the drug (Botulinum toxin type A)
– The total dosage 100 to 300 units
– Method of administration: “intramuscular
injection into bladder detrusor muscle”
– National Drug Code #, NDC, on package
• 100 units 00023-1145-01
• 200 units 00023-3921-02
– Retain drug invoice & provide to carrier if
requested
– Different MACs have different requirements
Revised CPT Code for 2013
Sacral Nerve Stimulation
• 64561 sacral nerve (transforaminal
placement) including image guidance, if
performed
(used percutaneously for initial testing)
– Do not bill fluoroscopic guidance
procedures 76000 and 77002 are
included in 64561
– Use modifier -50 for bilateral placements
2013 Proposed Bundling of
Ureteroscopy and Stent Placement
Current Coding
– 52353 urs./lithotripsy
Later this year
52353 with no stent
– 52332 stent
– separately billable
services
New single CPT code for
ureteroscopy/lithotripsy and
stent placement, which
will pay less than the
combination of codes
NCCI policy for 1/1/2013
• “ If a prostatectomy procedure necessitates
reconstruction of the bladder neck, the bladder neck
reconstruction is not separately reportable. For
example, CPT code 51800, (cystoplasty or
cystourethroplasty, plastic operation on bladder
and/or vesical neck…) should not be reported …will
not be reimbursed …with a prostatectomy CPT code
where the cystoplasty or cystourethroplasty is
necessitated by the prostatectomy procedure.”
• Do not bill 51800 with 55840(5)
• Do not bill 51999 with 55866
Source: 2013 National Correct Coding Initiative Policy Manual for Medicare services,
Chapter VII, Surgery: Urinary, Male Genitalia, Female Genitalia, page VII-8, section 20
Laparoscopic Urethral/Bladder Surgery
51990 …laparoscopy, surgical;
urethral suspension for stress
incontinence,…laparoscopic
Marshall Marchetti Krantz or Burch
procedures
- Reference: 2012 edition CPT source book
2013 Clinical Scenario
• Procedure: Robotic/laparoscopic radical
prostatectomy, robotic/laparoscopic bilateral
lymph node resection, and
robotic/laparoscopic Marshall, Marchetti,
and Krantz (MMK) urethropexy:
55866
38571-51
51990-51
Reference: CPT Assistant, August 2012, Volume 22, Issue 8
2013 E/M CPT Changes and Clarification
for Billing for Non Physician Providers
• “counseling /coordination of care with other
physicians, other qualified healthcare
professionals… (PA, NP, CNS, Midwife)*…”
– Can provide 82 E/M codes/services revised to
include “other healthcare professionals”
– Can bill E/M services on time alone
– Can provide counseling and coordination of care
– Can interpret & bill for fluoroscopic guidance
(76000, 77001)
*Source: 2013 CPT, Current Procedural Terminology,
Professional Edition
2013 Revisions for Urodynamics
“All…urodynamic…procedures…
can be performed by, or under the
direct supervision of, a
physician or other qualified
health care professional..”
2013 AMA CPT Manual, Urodynamics, page 284
2013 Revisions for Urodynamics
>“When
the individual only
interprets the results… of a
study,…the professional
component, modifier-26, should
be used to identify these
services.”<
2013 AMA CPT Manual, Urodynamics, page 284
New Urodynamic Rules for NPPs in
2013
• NPP performs or supervises an
office urodynamic study without
physician supervision:
– 51726 -TC
– 51726 -26
100% global fee payments
85% global fee payments
New Urodynamic Rules for NPPs in
2013
• With a urologist in the office an NPP
performs the technical portion of a
urodynamic study, and the urologist
interprets the study on the same day
– 51726 billed in urologist’s NPI; payment
at 100% of global fee
New Urodynamic Rules for NPPs in
2013
• Without a physician in the office an
NPP performs the technical portion of
a urodynamic study, and the urologist
interprets the study on the next day
– Day 1: PA…51726 -TC 100% global fee
– Day 2: MD.. 51726 -26 100% global fee
• Dates of service: Day 1 or Day 1 and 2
The Correction of Common
Coding Problems in Urology
Billing on Time Alone
• Who can bill on time alone?
– Physician**
– Non physician provider
• Bill in the name and numbers of NPP
• Can share time when MD bills on time
– RN/MT
• Only for private carriers, Not Medicare
• Can only code 99211 in physician’s
name/numbers
• Urologist must be in office suite
27
Failure to bill on Time may Lose Money
Criteria
• Over 50% of the encounter time is spent on
counseling and coordinating patient care
• Documentation of time spent (time in and time
out in minutes face to face), and of the content
of counseling
• No other key components are required to
determine the level of care
28
Evaluation and Management
Billing on Time Alone
• Established “old” patient:
– 5 minutes
– 10 minutes
– 15 minutes
– 25 minutes
– 40 minutes
99211
99212
99213
99214
99215
CPT
22 minutes
33 minutes
CPT: CPT Assistant; August 2004, Time is
average round off time, not threshold time
Medicare: IOM 2008; Threshold time, exact
time
29
Evaluation and Management
Family Counseling With or Without Presence of Patient
• Medicare: Patient must be present at counseling
– Code on time alone (99211 to 99215)
– Bill in patient’s name
– Diagnosis: a known ICD-9 code
• Private Carrier: Patient is not present at
counseling
– Cash payment from the family
– Code on time alone (in patient’s name)
– Diagnosis: a known ICD-9 code + V65.19
30
Excisions of Skin Lesions
May be Money Losers
• Cysts of Genitalia: Sebaceous
Cyst, epidermal inclusion,
condylomata (not on penis)
– 11420 to 11426 based on size of the
excised diameter, specimen
removed, not on size of the lesion
alone
31
Measuring for Lesion Removal
11421 ($153.32)* 11426 ($324.09)*
margin
(2.0cm)
1.0cm.lesion
excised diameter =
(lesion + 2x margin):
1.0cm+4.0cm=5.0cm
margin (2.0cm)
(2.0cm)
* 2013 Utah Medicare fee schedule
* Source
ICD-9 Diagnostic Coding Errors
Excision of Skin Lesions of Scrotum
• Cysts of Genitalia: Sebaceous Cyst, epidermal inclusion
– Primary Diagnosis ICD 9…706.2, 608.89
– Secondary Diagnosis ICD 9…459.0 (hemorrhage,
unspecified), 686.8 (other specified local infections), 686.9
(unspecified local infections), 695.9 (unspecified erythematous
condition), 782.0 (disturbance of skin sensation), supplies the
medical necessity
– Without a secondary diagnosis excision of a sebaceous
cyst may not be paid by Medicare or other insurance
carriers…reason for its removal is necessary
33
Incorrect Coding for Treatment of
“Bladder Neck Contracture”= a money loser
Correct Coding is Based on the Etiology of the BNC in the
male
• Congenital: ICD-9 753.6
– Incision – 52400
• Benign Hypertrophy (BPH): ICD-9 596.0
– TUIP
– 52450
– TUIBN – 52450 -52
– TURBN – 52500
34
Incorrect Coding for Treatment of
“Bladder Neck Contracture”= a money loser
Correct Coding is Based on the Etiology of the BNC in the male
• Postoperative Bladder Neck Contracture:
– TURBN – 52640
– TUIBN – 52640 -52
52276 post radical prostatectomy
(ICD-9 598.2)
• Laser vaporization of Bladder Neck
Contracture
– TU-LVBN 52214
35
Catheterization Coding Errors
• 51701 - Insertion of non indwelling bladder
catheter ( straight catheterization for
pvr)*$62.79/$28.77
• 51702 - Insertion of temporary indwelling
bladder catheter; simple (eg. Foley)
*$81.96/$31.90
• 51703 - Complicated (eg. altered anatomy,
fractured catheter/balloon) *$145.23/$85.79
• P9612 - Cath. for specimen (ua, c/s ), MC,
*$3.00
*2013 Boston, Medicare fee schedule, Mass. area # 01
Catheterization Coding Errors
Complicated Catheterization - 51703
• Use Complicated Catheterization for:
– Catheter passed over a guide wire
– Catheter guide
– Council tipped catheter
– Coude catheter
– Several catheters tried
– Instillation of lubricant into the urethra
– Difficult catheter removal
• Diagnoses: 598.9, 599.4, 596.0, 996.31, V53.6
Catheterization Coding Errors
• 51701 - Insertion of non indwelling bladder
catheter ( straight catheterization for pvr)
• 51702 - Insertion of temporary indwelling
bladder catheter; simple (eg. Foley)
• 51703 - Complicated (eg. altered anatomy,
fractured catheter/balloon)
• P9612 - Cath. for specimen (ua, c/s ), MC.
$3.00
Every Stent Placed is not a Stent
Placement of “Stents”
• Pre-operative “stents” for ureteral ID
– Ureteral “catheters”
– CPT: 52005
• Unilateral/Bilateral: Medicare…..52005
Bilateral: Private..……52005-50
or
52005-LT
52005-50-RT
Placement of Ureteral catheters
What ICD-9 code should I use?
• 52005, cystourethroscopy with ureteral
catheterization, with or without irrigation,
instillation, or ureteropyelography…
– Abnormal Urological Anatomy:
591, 593.3, 593.4, 593.5, 593.89
– Reason for primary surgery:
562.10 – 562.13 diverticulosis/diverticulitis /hemorrhage
153.3, 154.0 tumor of sigmoid or recto-sigmoid colon
180.9, 182.0, 218.1 uterine carcinoma or fibroid
– Not reimbursable with above diagnoses:
591, V07.8
A Stent is a Stent
Placement of “Stents”
• Post-operative “stents” for drainage
– Double J type ureteral “stents”
– CPT: 52332
• Bilateral: Medicare…….52332-50
Private..…….52332-50 or
52332-LT
52332-50-RT
Removal or Change Catheter/Tube
• Removal of foley, nephrostomy, cystostomy,
ureterostomy:……Bill E/M service
• Change or replace:
– Foley catheter 51702, 51703
– Suprapubic tube 51705, 51710
– Nephrostomy tube 50389, 50398
• Stent Exchange:
– 52332
– Do not bill for removal of the stent
Ureteroscopy Codes (CCI ver. 19.0)
52351 through 52355
• All codes include
• 52352
• 52353
52005, 52341*, 52344*
52310, 52315
52310, 52315, 52352*
52317*, 52318*
• 52354
52234 to 52240*
• 52355
52234 to 52240
• Do not include
74420 26
* can unbundle with modifier (i.e. 59)
Source: 2013 CPT
Bladder and Ureteral Calculi
Ferragamo, MA., J. Endourology 17, 7, September 2003
• Procedure: “Ureteroscopic laser lithotripsy of a left
ureteral stone and litholapaxy of a bladder stone”
– Large (>2.5cm.) bladder stone:
52318 - 59
52353 - 51
594.1
592.1
– Small (<2.5cm.) bladder stone
52353
52317 - 59 - 51
592.1
594.1
Urology Coding Update
Ferragamo, MA., J. Endourology 17, 7, September 2003
• Resection- bladder & ureteral/pelvic
tumors
- large bladder tumor
52240
188.2
52355-51
189.1
- small and medium bladder tumors
52355
189.1
52234(5) -51
188.2
Urology Coding Update
Medicare EOB Source: CMS 2005
• Hospital consultation (99254)
• Six hospital visits (99232)
• Transurethral resection of large bladder tumor
(52240)
• Transureteral resection of renal pelvic tumor
(52355)
Ureteroscopy Coding Changes
Medicare CCI. Version 14.3…October 1, 2008
• 52353 bundles 52310, 52315, 52351, 52352*
*modifier indicator changed from “0” to “1”; can
now unbundle with modifier (i.e. 59) but only
for a bilateral procedure (AUA and CPT)
Endourology Coding Update
after October 1, 2008
• Findings: left and right ureteral stones
Procedure: “Ureteroscopic laser lithotripsy of
a left ureteral stone and ureteroscopic extraction
of a right ureteral stone, and bilateral JJ stents”
CPT
52353 LT
52352 59 RT
52332 50
ICD-9
592.1
592.1
591, V07.8
Ureteroscopy Coding Changes
Medicare CCI. Version 14.2…July 1, 2008
• 50590 bundles 52351*, 52352*, 52353*
*modifier indicator changed from “0” to “1”; can
now unbundle with modifier (i.e. 59) but only for
a bilateral procedure (AUA and CPT)
Endourology Coding Update
• Procedure: (left ureteral stone and right renal
pelvic stone)
“ESWL of a right renal pelvic stone, KUB
evaluation, left ureteroscopy and bilateral JJ
stent”
CPT
50590 RT
74000 26
52351 59 LT
52332 50
ICD-9
592.0
592.0
592.1
591, V07.8
Endourology Coding Update
• Procedure: (left ureteral stone and right renal
pelvic stone)
“ESWL of a right renal pelvic stone, KUB
evaluation, ureteroscopic lithotripsy of a left
ureteral stone. and bilateral JJ stents”
CPT
50590 RT
74000 26
52353 59 LT
52332 50
ICD-9
592.0
592.0
592.1
591, V07.8
Unbundling – 52344
Ferragamo, MA., J. Endourology 17, 7, 2003
• Example: Left Renal Colic, Left Ureteral Stone and
Stricture: Cystoscopy and retrograde pyelogram,
ureteroscopic balloon dilation of lower ureteral stricture,
under X-ray control, ureteroscopic extraction of ureteral
stone, and JJ stent placement.
CPT:
ICD-9:
52344 - 59
74485 - 26
52352 - 51
52332 - 51
74420 - 26
593.3
593.3
592.1
591, V07.8
592.1
Example of Unbundling – 52344
Medicare EOB NY
• Ureteroscopic ureteral balloon dilation 52344 59
• Ureteroscopic extraction of ureteral stone 52352 51
• Placement of JJ stent 52332 51
• Interpretation of retrogarde pyelogram 74420 26
Endoscopic Urological Coding
Percutaneous Nephrostolithotomy
with or without dilation, endoscopy, stenting,
lithotripsy, and/or basket extraction
• 50080 < 2cm. Stone
• 50081 > 2cm. Stone
May charge for:
50395 - percutaneous access*
or
50392 - placement of nephrostomy tube
50394 – nephrostogram
50577 – incision of infundibulum
*(if more than one site accessed, add 50395-59 or use code 50395-22 )
Source: Ferragamo, M.A., Contemporary Urology, January 2007, pages 6-13
Endoscopic Urological Coding
Percutaneous Nephrostolithotomy
with or without dilation, endoscopy, stenting,
lithotripsy, and/or basket extraction
• 50080 < 2cm. Stone
• 50081 > 2cm. Stone
May charge for:
52005 – cystoscopy and retrograde pyelogram
or
52332 – cystoscopy and placement of ureteral stent
74420-26 - reading of retrograde pyelogram
74425-26 - reading of nephrostogram
Source: Ferragamo, M.A., Contemporary Urology, January 2007, pages 6-13
Private Carrier Coding for PCNL
•
•
•
•
Percutaneous Nephrostolithotomy
Percutaneous Access
Cystoscopic insertion of JJ stent
Interpretation of nephrostogram
50081
50395
52332
74425
Private Carrier - Bill Fee for Service
•
•
•
•
•
•
Percutaneous Nephrostolithotomy
Percutaneous endopyelotomy
Percutaneous renal access
Performance of nephrostogram
Interpretation of nephrostogram
Cystoscopy and retrograde pyelogram
Endoscopic Urological Coding
Transurethral Resection of the Prostate Gland
• Code: 52601: TURP/Vaportrobe/Button TURP
– 90 day global, includes cystoscopy and
urethral dilation, urethrostomy, vasectomy
– Place of service: 21, 22, 24
– ICD 9 600.01, 185
– “Once in a life time procedure”
Source: Current Procedural Terminology, CPT 20121
Criteria for Ambulatory TURP
Place of service, POS, 22, 24
•
•
•
•
•
Age: < than 75 years of age
Prostate size: < than 50 grams by ultrasound
Coagulation: no bleeding diathesis
Medication: no anticoagulation therapy
Anesthesia: no serious co-morbidity problems
• Inpatient: if outpatient criteria not met
Source: Milliman Care Guidelines Inpatient and Surgical Care, 15th edition
Button (electrode) TURP…52601
Electrical Vaporization of Prostate
60
In 2009 CPT Revised Coding for a
Repeat TURP
• 52630: transurethral resection; residual or
regrowth of obstructive prostatic tissue
including control of postoperative bleeding,
complete (vasectomy, meatotomy,
cystourethroscopy, urethral calibration
and/or urethral dilation, and internal
urethrotomy are included)
Repeat Transurethral Resection of the
Prostate Gland (January 1, 2009 CPT)
>Revised Coding<
• Repeat TURP in the global period
– 52630 -78 (CPT: treatment of a complication)
• Repeat TURP after the global period
– 52630
*2010 CPT Coding Professional Edition, AMA
Laser Vaporization 52648
Repeat vaporization of the prostate gland
• Repeat Greenlight laser in the global period
– 52648 78 (CPT: treatment of a complication)
• Repeat Greenlight laser after the global period
– 52648
*2011 CPT Coding Professional Edition, AMA
Treatment of Bladder Tumors
TUR of Solitary Bladder Tumor
•
MPFSDB (Fee) is based on Tumor Size:
– 52224 < 0.5cm.
•
minor
$199.72*
– 52234 0.5 – 2cm. small
$241.22
– 52235 2 – 5cm.
medium
$283.41
– 52240 > 5cm.
large
$384.46
MPFSDB - 52224-52240 have Zero day globals
* 2013 unadjusted Medicare fee schedule
Treatment of Multiple Bladder Tumors
• Medicare: (52234, 52235, and 52240)
- Code for the Largest tumor only
- Charge only one code per day
- Use 52224 - 59 for lesion < 0.5cm.
- Use 52204 - 59 for biopsy
• Private:
- Add all tumors & bill on total Volume
- May also code for biopsy
Treatment of Bladder Tumors
Carcinoma in Situ 233.7, 596.7, 239.4
• Single flat lesion fulguration:(52234,
52235, 52240)
• Multiple flat lesions fulgurations:
Medicare: Code the largest lesion fulgurated
Do not code for biopsy of lesion
Private: Code total volume fulgurated
• Bladder Biopsy:
- Code 52204(+/- Fulguration)
Urethral/Bladder Biopsy
• 52204 Cystourethroscopy with Biopsy(ies)
– Report only once regardless of # biopsies
taken
– Bladder, prostatic urethra, anterior urethra
– 52204 22 for multiple biopsies
52204
Biopsy of lesion
Any size, normal mucosa
Fulgurate bleeder from/at
the biopsy site
Not a treatment
$370.17/$139.49*
cannot be billed together
or
52224
Removal of lesion
0.5cm. or less
Fulgurate the complete
lesion/base
Treatment of lesion
$695.77/$197.67*
*2013 unadjusted Medicare fees
schedule
52204
Biopsy of lesion
or
52214
No biopsy performed
Any size, normal mucosa
ulcer/bleeder
Fulgurate bleeder at the
biopsy site
Fulgurate ulcer or
bleeding vessel
Not a treatment
$373.91/$140.51*
can be billed together
Treatment of above
$672.97/$172.84*
*2013 unadjusted Medicare fees
Coding Questions??
Call Me! - I’d be Happy to Help!
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