Coding Strategy

Modifier 59 sometimes will rescue your reimbursement.

Just when you’re finally getting a handle on all the 2010 coding changes, here comes round two of the Correct Coding Initiative (CCI) edits. Version 16.1, which took effect April 1, will tie your hands when coding many common urology procedures, including prostate biopsies and urethral dilations.

Heads up: CCI 16.1 includes 2,054 new active pairs and 1,947 modifier changes, says Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions Inc. in Clearwater, Fla.

“For urology, there will be 78 edit pair additions and two edit pair deletions,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.To ensure you get paid appropriately for your urologist’s services this quarter, here’s the rundown of the most important changes.

Say Goodbye to Biopsy with Several Prostate Procedures

You can no longer report prostate biopsy codes 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) or 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance) with 52630 (Transurethral resection; residual or re-growth of obstructive prostate tissue including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]). Your payer will reimburse you for 52630 but deny the biopsy codes, and you cannot use a modifier to separate these new edits.

“I have a major issue with the bundling of 55700 and 52630,” laments Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. Kater says her urologists perform a good number of prostate biopsies transrectally and 55700 is what she uses because the descriptor says “any approach.” When you are performing two separate procedures utilizing two different approaches, how can they be bundled?”

Silver lining: CCI also bundles 55705 (Biopsy, prostate; incisional, any approach) into 52630, but the edit carries a “1” modifier indicator. Therefore, you can break that bundle if clinical circumstances warrant separate reporting.

Additionally: As of April 1, transurethral resection of the prostate (TURP) code 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) and laser prostatectomy codes (52647-52649) are mutually exclusive with saturation biopsy of the prostate under anesthesia (55706).

The 52601/55706 and 52648/55706 bundles have a modifier indicator of “0” so you can never bill those codes together. On the other hand, the 52647/55706 and 52649/55706 bundles both have a modifier indicator of “1,” which means you can report the codes together underspecific clinical circumstances using a modifier such as modifier 59 (Distinct procedural service), Ferragamo says.

You will also find prostate biopsy listed as a column 2 code (55706), forming mutually exclusive edits with the following column 1 codes:

• Transurethral destruction of prostate tissue (53850-53852)
• Prostatectomy (55801-55845, 55866)
• Cryosurgical ablation of the prostate (55873).

The modifier indicator for all of these above edits is “1.” You can break the bundles when clinical circumstances warrant.

Beware Multiple Urethral Dilation Edits

CCI 16.1 hits urethral dilation coding hard. To find out what edits you need to apply to your urology practice pronto, subscribe to the Urology Coding Alert.

Editor: Leesa A. Isreal, CPC, CUC, CMBS

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Don’t sweat reporting 38220-59 if you meet these Medicare-approved conditions.

If your oncologist takes both a bone marrow biopsy and a bone marrow aspiration, whether you’ll see Medicare reimbursement depends on the two guidelines below. But watch out: With OIG scrutiny and a HCPCS twist, these guidelines will put your coding savvy to the test.

Append 59 for Different Sites and Encounters

Because a bone marrow biopsy and a bone marrow aspiration can provide different diagnostic information for certain leukemia evaluations, taking both specimens from the same patient on the same day isn’t unusual, according to R.M. Stainton Jr., MD, president of Doctor’s Anatomic Pathology in Jonesboro, Ark.

Snag: Medicare and some other payers use the Correct Coding Initiative (CCI) edits to restrict how you bill for “sequenced” surgical procedures through the same incision. For biopsy and aspiration, CCI bundles the following codes:

• 38220 — Bone marrow; aspiration only
• 38221 — … biopsy, needle, or trocar.

Silver lining: You may report 38220 and 38221 together, according to the NCCI Policy Manual for Medicare Services, Chapter 5, Section E, if the physician performs the procedures at either of the following

• Different patient encounters
• Different sites, meaning “in different bones or two separate skin incisions over the same bone.”

For CMS and other payers who use the CCI edits, if these two procedures meet one of the above listed criteria, you may override the edit by appending modifier 59 (Distinct procedural service) to 38220 and receive payment for both services, Stainton says.

Additional 59 support: CMS posted “Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service” on its CCI overview Web page. In the article, you’ll find the following examples, which echo the CCI manual criteria, of when CMS considers modifier 59 use to be appropriate for bone marrow aspiration and biopsy:

• Different sites: contralateral iliac crests; iliac crest and sternum
• Different incisions: same iliac crest
• Different encounters.

Beware: In one study, the Office of Inspector General (OIG) found that coders inappropriately used modifier 59 more often with 38220/38221 than any other code pair. So you want to take extra care to append modifier 59 only when appropriate. If the procedures occur through the same incision, you should not use modifier 59 to report 38220 and 38221 together to Medicare. For guidance on that situation, see the next section.

Capture Same Site With G0364

Medicare indicates you shouldn’t use modifier 59 to bill 38220 and 38221 together for a bone marrow biopsy and aspiration through the same incision. But that doesn’t mean you have no recourse.

Know the G code: For sequenced procedures, you’ll report 38221 for the biopsy as usual. Then you can also report the aspiration to Medicare using G0364 (Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service), says Joyce Matola, billing manager for The Center for Cancer and Hematologic Disease in New Jersey. So be sure to let the physicians know that you need documentation on the number of incisions and the specific sites involved.

Commercial payer caution: Contact your payer for specific coverage guidelines before submitting your claim for bone marrow aspiration and biopsy. Some commercial and managed care payers may have guidelines that allow you to report 38220 and 38221 for sequenced procedures. Others may require you to report only the most extensive procedure.

@ Oncology Coding Alert

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Question: Notes indicate that the gastroenterologist performs a rigid sigmoidoscopy; during the encounter, he also performs an anoscopy without anesthesia and three biopsies of the mucous membrane. How should I report this episode? Can I report the exam separately with 46600?

Answer: You can report a single code for these three services. On the claim, report 45305 (Proctosigmodoscopy, rigid; with biopsy, single or multiple) for the sigmoidoscopy, the anorectal exam, and the three biopsies.

Why: When the gastroenterologist performs an anoscopy (46600 [Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) or mucous membrane biopsy during a sigmoidoscopy, the services are bundled into 45305.

AUDIO TRAINING EVENT: Colonscopy Coding Clinic with Jill Young. How to code screening-turned-diagnostic colonscopies, documentation musts, modifier musts, compliance heads up & more.

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