Investigating Common CPT Coding Errors in Urology Billing

Identifying the Wrong CPT Code

Navigating the complex world of medical coding often leads to differing opinions and interpretations. When it comes to coding, presenting the same operative report to five coders can result in different codes, demonstrating the importance of staying updated with the latest guidelines from the American Medical Association. This variability is largely influenced by individual understanding of anatomy and the quality of communication with providers. The field of medical coding, heavily reliant on the current procedural terminology code set, is filled with disagreements between coders and payers, making it both challenging and fascinating.

It all comes down to your understanding of anatomy, how well you communicate with your providers, and the accurate application of the current procedural terminology codes. Due to the complexity and variations in coding guidance, as well as differences in interpretations by payers, you will frequently encounter differences of opinion between coders and payers.

For instance, as a urology coder, you may come across the codes 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) and 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)).

These codes, from the current procedural terminology code set, are commonly used when a provider is called into the hospital to prevent injury during surgical procedures involving the urinary system, including always reported separately for clarity in billing. The urologist will insert the urethral catheters and remove them at the end of the procedure, utilizing specific current procedural terminology codes. The correct code for this scenario is 52005, not 52332. However, it is crucial for the provider to use clear language in their documentation to effectively communicate this to the coder and ensure proper payment, emphasizing the importance of current procedural terminology guidelines. “We are trying to educate the providers that their documentation is key and will help the coder choose the right code,” said Maldonado.

The coder was facing confusion in this situation because the provider continued to include conflicting information in the operative report, complicating the use of the accurate current procedural terminology code.

Retrieving Tumor Size Information from the Pathology Report

Navigating bladder biopsy codes can be quite challenging. One important thing to note is that you should not rely on the pathology report to determine the size of bladder tumors, as you would normally do with the codes mentioned below:

– 52224 (Cystourethroscopy, with fulguration or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy)
– 52234 (Cystourethroscopy, with fulguration and/or resection of SMALL bladder tumor(s) (0.5 up to 2.0 cm)), a code from the current procedural terminology code set for urological procedures, reflecting the updates for 2024.
– 52235 (Cystourethroscopy, with fulguration and/or resection of MEDIUM bladder tumor(s) (2.0 to 5.0 cm))
– 52240 (Cystourethroscopy, with fulguration and/or resection of LARGE bladder tumor(s)), a procedure used to report using the current procedural terminology code set for urological surgery.

Instead, it is crucial to gather all lesion measurements from the provider’s notes in the operative report. The provider performing the resection or fulguration of the bladder tumor is the only one who can accurately provide the approximate size of the lesion, and this information should be documented in the operative report. The pathology report should not be used because the tissue shrinks once it is placed in the fixative, resulting in an incorrect size measurement. If the procedure notes do not provide an exact size, you should use code 52224, as outlined in the current procedural terminology code set for 2023.

Remember, when there are multiple tumors, always code based on the largest lesion. Adding multiple lesions together is not allowed, as per current procedural terminology code guidelines for procedures on the urinary system. Additionally, ensure that the correct size is documented in the operative report, which is vital for accurate current procedural terminology coding.

 Documentation Protocol for Claims with Unlisted CPT Codes or Modifier 22

Do not send in an operative report and a cover letter for claims with unlisted CPT codes or CPT codes with modifier 22 Unusual procedural service, as per the updates for 2024 issued by the American Medical Association. Kindly wait for the insurer, possibly Medicare, to request documentation including the relevant current procedural terminology codes, as these may change with the updates for 2024. Once the request is received in 2023, submit your documentation, including the operative report and cover letter, ensuring the current procedural terminology codes are correctly used. Remember, the operative report is crucial as it describes the procedure performed when there is no appropriate CPT code or explains the unusual aspects of the service that justify additional payment with modifier 22. The cover letter should provide details about the procedure and explain in simple terms why it was different, required more time, or a higher skill level, as the claims reviewer may not have extensive medical knowledge.

Common Mistakes in Billing and Postoperative Period Management

Another mistake is charging for a visit that is already covered in the global period for a surgery or procedure. This rule only applies to specific codes that have a global period. Remember, you cannot bill for an evaluation and management service if it is connected to the surgical procedure, as per the latest guidelines from the American Medical Association. However, if the evaluation and management service is performed for a separate identifiable service, then it can be reported on the same day as the procedure. You can only bill for both the visit and the procedure if the decision to perform the surgery was made during the visit and the modifier -57, Decision for Surgery, is used, according to current procedural terminology guidelines.

Please avoid resubmitting returned or rejected claim forms. If your claim is returned or rejected for any reason, submit a completely new claim instead. Do not resend the old one and label it as “corrected.” This will only lead to a second rejection.

Also, do not bill for an unrelated visit during the postoperative period without using the modifier -24, Unrelated E&M Service by the Same Physician During a Postoperative Period, guidelines updated by the American Medical Association suggest. A visit during the postoperative period must be unrelated to the surgery to be billed in 2023, and it should include the modifier -24, per current procedural terminology guidelines updated by the American Medical Association. The diagnosis code for this visit should be completely unrelated as well, in line with updates for 2024 from the Centers for Medicare & Medicaid Services.

Medicare Coverage Guidelines for Preventative Visits and Services

It is extremely important to avoid billing Medicare for preventive visits and related services, as Medicare does not provide coverage for these expenses. Patients are responsible for paying these charges, and there is no need for a signed waiver. However, Medicare does cover a “welcome to Medicare” visit and one annual visit per year. It is crucial to have a clear understanding of Medicare’s coverage guidelines in order to accurately bill and ensure that patients receive the appropriate care without any unexpected expenses. By following Medicare’s guidelines and billing practices, healthcare providers can ensure compliance and maintain transparent communication with their patients regarding covered services and associated costs.

Q: What is the importance of code updates for urology?

A: Code updates for urology, including current procedural terminology (CPT) codes and category III codes, are essential to reflect changes in procedures, ensure accurate billing, and comply with the latest coding guidelines.

Q: How are urology procedures reported with CPT codes?

A: Urology procedures are reported with specific CPT codes that describe the services provided, ensuring proper documentation for reimbursement and tracking medical necessity.

Q: What is the impact of the new category III codes on urological practices?

A: The introduction of new category III codes in urology as of January 1 can affect billing, coding, and reimbursement practices, requiring healthcare providers to stay updated with the latest coding changes by the American Medical Association.

Q: Can urologists bill for shock wave therapy with CPT codes?

A: Yes, extracorporeal shock wave therapy performed by urologists can be billed using relevant CPT codes, but it is crucial to follow coding guidelines and document medical necessity as stated by the American Medical Association.

Q: How should urologists handle the reporting of integrated neurostimulation systems for bladder dysfunction?

A: Urologists should ensure proper reporting of integrated neurostimulation systems for bladder dysfunction, including using the correct CPT codes, documenting medical necessity, and following billing and coding guidelines.