Coding Update

Educational Objectives

The goal of this program is to improve the accuracy of diagnostic coding. After hearing and assimilating this program, the clinician will be better able to:

1. Apply new rules to accurately code doses of bacillus Calmette-Guérin.

2. Implement new guidance addressing coding for laparoscopic robotic procedures.

3. Appropriately use the 62 modifier for co-surgeons in cases billed to Medicare.

Summary

2020 ICD-10-CM diagnostic codes: coding using the International Classification of Diseases, Tenth Revision, Clinical Modification became effective October 1, 2019; changes in 324 codes (273 new, 30 revised, 21 deleted); 7 changes for urology (4 new, 2 revised, 1 deleted); unspecified diagnostic codes are identified by a gray bar and should be used only in limited circumstances where no specific code exists or documentation for a specific code is lacking; N30.90 and N30.91 are unspecified diagnoses; many carriers do not reimburse for claims for an unspecified diagnosis; unspecified codes were previously identified with an inverted blue triangle

New ICD-10-CM codes for urology: R82.81-pyuria; includes sterile pyuria; R82.89-other abnormal findings on cytologic and histologic examination of the urine; code to use if performing cystoscopy or ureteroscopy because of findings in urine suspicious or positive for urine cytology; hyperuricosuria also has a new code; Z86.002-Z code usually refers to a personal history of something; in this case, personal history of in situ neoplasm of other and unspecified genital origin; used for a patient with a history of high-grade prostatic, vaginal, or vulvar intraepithelial neoplasia

Revised codes: N35.814-for dilation or repair of a urethral stricture; word anterior dropped; Z45.42-new code for encounter, adjustment, and management of a neurostimulator or neurostimulator electrode; R82.993-corrected misspelling of hyperuricosuria

2020 Current Procedural Terminology (CPT) procedural codes: effective January 1, 2020; changes in 384 codes (244 new, 72 revised, 68 deleted); 11 changes for urology (7 new, 1 revised, 3 deleted); no new or deleted CPT codes in the urological section; 1 revised code in the surgical section (eg, 54640 orchidopexy); no new, deleted, or revised urogynecology codes in the female genital section; no new, deleted, or revised laparoscopic robotic codes for urology or urogynecology

Telecommunication: new codes for use with telecommunication; new codes led to deletion of 99444 (online evaluation and management [E/M] service with no time frame)

Biofeedback: 2 new codes relate to biofeedback; 90912 is for biofeedback training of the perineal muscles or anorectal or urethral sphincter; includes electromyography (EMG) or manometry (cannot bill extra); includes initial time of 15 min; +90913 is an add-on code (cannot bill alone); use +90913 in conjunction with 90912 for additional 15 min of teaching biofeedback; when using add-on codes, do not decrease the fee and do not add modifier 51; previously had 1 code for biofeedback training of the rectal or urethral sphincter that had no time frame; the fee remained the same regardless of the amount of time spent with the patient; with current codes, 90912 covers the first 15 min and +90913 covers an additional 15 min

Grafting of autologous material: new code 15769; use for a flap in the peritoneal cavity to help close a fistula; can be a free flap or a pedicle flap; old code 20926 was deleted

2020 new Category III CPT code: speaker does not recommend; alphanumeric code 0582T refers to transurethral ablation of malignant prostate by high-energy water vapor thermotherapy; includes imaging and needle guidance; code for the Rezum procedure is 53854 (but only in the treatment of benign prostatic hyperplasia, ie, not cancer of the prostate); Category III codes are designed to enable Centers for Medicare and Medicaid Services to track the frequency of the procedure; speaker does not think Category III codes should be used in place of an unlisted CPT code because there is no fee schedule for Category III codes (ie, physicians do not get reimbursed); payment may occur only when data become available to support the medical necessity, safety, and efficacy of the procedure

Orchiopexy: code 54640 has been revised from the inguinal approach with or without hernia repair to orchiopexy including the inguinal or scrotal approach; phrase “with or without hernia repair” deleted; add modifier 50 to 54640 for bilateral procedures; use codes for hernia repair if inguinal hernia repair is required; bill for trans-scrotal bilateral orchiopexy with code 54640, modifier 50, and ICD-10-CM diagnostic code of Q55.22 (retractile testicles); same code (54640-50) used for inguinal or scrotal orchiopexy; also bill for hernia repair with reference to the patient’s age; code for a patient aged 1 yr is 49500 with diagnosis of K40.90 (inguinal hernia nonrecurrent, nonobstructive, and not producing gangrene)

Economics of urology for 2020: annual deductible in 2020 for Medicare Part B is $198 (increase of $13 from 2019); conversion factor changes every year; used to convert relative value units of every service or procedure to dollars and cents; conversion factor in 2019 was 36.0391; increased in 2020 to 36.0896 (increase of ≈5 cents); most payments for 2020 remain relatively flat

E/M services: minimal percentage changes to E/M services for new or established patients; fees vary from 2019 by <$1.00

Changes in Medicare payments for office procedures from 2019 to 2020 in New York City: irrigation of the bladder increased; insertion of a temporary catheter increased; vasectomy decreased; biopsy of the prostate, EMG studies, and urethral dilation for men and women increased by 1% to 3%

Hospital procedures: transurethral resection of a large bladder tumor, laser prostatectomy, transurethral resection of the prostate, laparoscopic radical prostatectomy, cystectomy, and ileal conduit increased by ≈2%

Largest increases for urologic procedures in 2020: cystoscopy increased 11%, rectal pressure test (51797) increased 17%, cystoscopy with urethral dilation or calibration (52281) increased, urethral dilation with filiform and follows (53620), and initial UroLift implant (52441) increased 6.8%

Largest decreases: sonographic assessment of postvoid residual urine volumes (decreased 19%), SpaceOAR (55874), transforaminal placement of a neuro-electrode, and intramuscular or subcutaneous injection (96372)

Bacillus Calmette-Guérin (BCG): many practices split doses of BCG between patients because of the current shortage; a new Healthcare Common Procedure Coding System (HCPCS) code for BCG became effective July 1, 2019; new code of J9030 is for live attenuated BCG; submit bill based on the number of milligrams used for intravesical instillation; one vial of BCG contains ≈50 mg of freeze-dried powder; 1 mg equals 1 unit; if using the entire vial (50 mg), instruct coders to put the number 50 in column 24G to represent 50 units; in the past one vial equaled 1 unit, but this is no longer the case; for split doses, bill the instillation charge (51720), the J9030 code for the BCG, and a drug report; one-half of a vial is 25 mg, so put 25 in column 24G of the 1500 form; must include a drug information report with billing; payers will not reimburse for BCG without the drug report; enter drug information in box 19 of the 1500 form or the equivalent space in an electronic health record; include the name of the drug (TICE BCG), administered dose in milligrams (≤50 mg), route of administration (intravesical), and the national drug code number; be prepared to provide a paid invoice for the BCG if requested by the payer

Pelvic exenteration: code is 51597; used for complete pelvic exenteration; includes excision of the bladder, prostate, anus, rectum, and a portion of the sigmoid colon in men; also includes bilateral pelvic lymphadenectomy and the formation of a colostomy; includes excision of the bladder, uterus, uterine tubes, and ovaries in women; confusion can arise because some physicians bill with this code believing it refers to an anterior exenteration in women; this is not the case; 51597 also includes excision of the anus, rectum, and a portion of the sigmoid colon, bilateral pelvic lymphadenectomy, and the formation of a colostomy; urinary diversion is billed separately; use code 508** for open ileal conduit; add modifier 50 if both ureters are reimplanted; use 50815 for a sigmoid conduit; add modifier 50 if both ureteral orifices are connected to the conduit; use 50825 for continent neobladder

Laparoscopic robotic cystectomy: American Urological Association (AUA) recommended use of codes for open procedures, eg, 51550 for a partial cystectomy through 51595 for a full cystectomy, ileal conduit as a urinary divergence, and a pelvic lymphadenectomy; AUA believed the codes were acceptable for robotic surgery because the approach was not mentioned in the definition of the codes; laparoscopic procedures did not have specific CPT codes; new guidance issued May 10, 2019; AUA now advises members to report any laparoscopic procedure that lacks a specific laparoscopic CPT code by using the appropriate unlisted code for that organ (eg, report laparoscopic robotic cystectomy using 51999 for unlisted laparoscopic procedure in the bladder)

Simple (not radical) laparoscopic robotic prostatectomies: do not use the codes for open procedures (eg, 55821 for suprapubic, 55831 for retropubic); use of open codes is no longer correct or appropriate; use 55899 (unlisted procedure in male genital system); do not use the code for radical prostatectomy for billing a simple prostatectomy; use 55899 for simple laparoscopic robotic prostatectomies

Change in use of modifier 62 for co-surgeons: not every code will accept modifier 62 for a co-surgeon; necessary to have a code such that 1 surgeon can do 1 part of the CPT code and a co-surgeon can do another part; clinically involves 2 primary or co-surgeons; change affecting all departments states that co-surgeons must be of separate specialties to bill Medicare; for private or commercial carriers, co-surgeons may be of the same specialty but may have different expertise; each surgeon must perform a separate part of the CPT procedure; each must document with a separate individual operating room (OR) report or a single OR report delineating in detail which part of the procedure was performed by each surgeon; co-surgeons must generally submit the same CPT code with modifier 62

Example case 1: 51590, open code for total cystectomy and ileal conduit; urologist performs the cystectomy and uses 51590, adding modifier 62; general surgeon performs the ileal conduit and uses the same code with modifier 62; diagnosis is bladder cancer of the lateral wall; important for co-surgeons to have separate specialties when coding with Medicare

Example case 2: patient undergoes total prostatectomy, ileal conduit, and bilateral lymphadenectomy; the 2 co-surgeons are of different specialties; the urologist performs the cystectomy and the bilateral pelvic lymphadenectomy (included in code 51595); the general surgeon documents the same code with the modifier 62 for the surgical construction of the ileal conduit; for this case, the urologist can also bill for open prostatectomy (55840) and the general surgeon can bill as an assistant for the prostatectomy using modifier 80; 2 urologists performing the same procedure cannot bill as co-surgeons; recommended that 1 urologist bills for procedure (51595 cystectomy, ileal conduit, and bilateral pelvic lymphadenectomy) and the other urologist bills as an assistant despite performing the ileal conduit; first urologist bills for open radical prostatectomy and the second urologist bills as an assistant

Case example 3: same procedure performed laparoscopic robotically; the urologist bills with code 51999 (unlisted laparoscopic robotic procedure for the bladder) for the radical cystectomy and adds modifier 62; unlisted codes do not take modifiers in general, but do take modifier 80 or 82 for an assistant or 62 for a co-surgeon; the general surgeon performs the ileal conduit and bills with the same code (51999-62); 2 urologists cannot be co-surgeons if billing Medicare

Relevance for urologists: many urologists receive a salary regardless of coding; many urologists do not perform their own coding; the urologist is ultimately responsible for the accuracy of coding, regardless of who does it; the urologist is susceptible to any denials, sanctions, fees, penalties, or requests for return of payment

Readings

American Urological Association: AUA coding resources. https://www.auanet.org/practice-resources/coding-and-reimbursement/coding-resources-and-information/aua-coding-resources. Accessed June 15, 2020; Centers for Medicare and Medicaid Services: 2020 ICD-10-CM. https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-CM. Accessed June 15, 2020; Centers for Medicare and Medicaid Services: HCPCS quarterly update. https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update. Accessed June 15, 2020.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Ferragamo was recorded at Surgical, Pharmacological, and Technological Advances in Urology, held December 12-14, 2019, in New York, NY, and presented by NYU Robert I. Grossman School of Medicine. For information about upcoming CME opportunities from NYU Langone Health, please visit Med.nyu.edu/education/continuing-medical-education. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

UR431601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.