Urology coding is unique, especially with the continuous stream of industry changes and evolving compliance standards in urology revenue cycle management.

Keeping up with all these changes is a 24/7 job by itself not to mention implementing all of them. You hate to admit it but some most likely fall through the cracks.

Vigilance is key. Some coding changes that occurred in September 2012 related to avoidance of unbundling instillation, in/out catheter, and they bear repeating to ensure compliance and address those questions many urologists may still be pondering about coding for instillation based on the drug being used and charge separately for drugs instilled

Questions you may have been or continue to be asking yourself (from American Urology Today in September 2012) include:

Q) When instilling an agent into the bladder via temporary catheter, can one charge for the in-and-out catheter (51701) as well as the lavage (51700)? An example would be giving a pentosan polysulfate (Elmiron) cocktail for the treatment of interstitial cystitis or administering bacillus Calmette-Guérin (BCG [TheraCys, TICE BCG]) for treatment of bladder cancer.

A) You have actually provided two examples that require the use of different codes…

The first example of the pentosan cocktail for IC is correctly coded using 51700—Bladder irrigation, simple, lavage, and/or instillation. The simple answer to your question about the 51701—Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) is no; one cannot bill for the 51701 with the 51700. In fact, if you look at the bundling matrix or the bundled codes for 51700 in http://AUACodingToday.com/, code 51701 is included and can never be unbundled. This is common for most of the urology procedure codes.

Further, from a CPT perspective, you cannot accomplish an instillation without using some type of delivery device, so it would be incorrect coding from CPT’s perspective to report the insertion of the catheter unless you are using a separate catheter to accomplish some other medically necessary service during the same visit. Therefore, you should not code the 51701 with 51700 to any private payer unless it is clearly a separate insertion for a separate reason. In the second example you provide, the BCG instillation should be coded as 51720—Bladder instillation of anticarcinogenic agent (including retention time). Again, code 51701 is bundled into the 51720 and unbundling is never allowed. Like code 51700, the CPT inference would require the use of a catheter to instill the anticarcenogenic agent.

In short, you should not bill the 51701 with either 51700 or 51720 to any payer if the service you are providing that day is solely the instillation of a substance in the bladder. Make sure that you are coding correctly for the instillation based on the type of drug you are using and charge separately for the drugs that are instilled.

Q) How would you code for cystoscopy with instillation of bupivacaine (Marcaine, Sensorcaine) and gentamicin (Garamycin, Gentak) into the bladder and trigger point injection with a mixture of triamcinolone (Kenalog), bupivacaine, and onabotulinumtoxinA (Botox)? (Editor’s note: This question is based on an operative note and has been edited for length.)

A) First, we will address the cystoscopy with instillation of the bupivacaine and gentamicin. The operative note indicates that a complete diagnostic cystoscopy with inspection of the bladder was performed. “After this was completed, a rigid cystoscope was assembled, lubricated, and placed through the urethra into the urinary bladder in atraumatic fashion. A survey of the entire bladder was performed. The patient’s old scar in the left lateral wall of her bladder was identified. There were no other abnormalities in her bladder. Her bilateral ureteral orifices were orthotopic position. The bladder was then emptied.”

The operative note also indicates: “A mixture of bupivacaine and gentamicin was then instilled into the bladder through the cystoscope.” Unfortunately, there is no code that reflects both a cystoscopy and instillation. Of course, a code for instillation, 51700, is available (see related question above). The 51700 code does not specify that the delivery device must be a catheter, and code 52000—Cystourethroscopy (separate procedure) does not include reference to an instillation of any type. The operative note indicates that the diagnostic and therapeutic portions of the procedure were separate. Therefore, we would recommend coding both the 52000 and the 51700-59 for this portion of the procedure.

The other part of the procedure indicates injection of triamcinolone and bupivacaine into three separate injection sites: at 4 o’clock and 7 o’clock of the levator ani and into the left thigh. This was then followed by injection of onabotulinumtoxinA into the same three areas.

The procedure description in the introduction of the operative notes lists the injections as trigger point injections. However, the body of the operative note references the location of each injection. We would encourage any operative note to be clearly descriptive and match the other parts of the operative note, such as findings and procedures performed in detail. In other words, all introductory parts of the note are considered a summary for which the body of the note should provide matching detail.

As such, we would recommend the trigger point injection code 20552 for all injections. Trigger point injections are covered under LCD restrictions for multiple jurisdictions and should be reviewed prior to reporting, making certain that supported diagnoses for muscle spasms are clearly indicated in the patient’s medical record.

Coverage of triamcinolone, bupivacaine, and onabotulinumtoxinA in this instance is not the concern of the office, as the service was provided under general anesthesia in facility that would be paid separately for the drugs used. If provided in an office setting, triamcinolone and bupivacaine can be reported under HCPCS codes if trigger point injections are covered. OnabotulinumtoxinA is a separate issue covered in many states for the treatment of muscle spasms, but not in all areas. The LCD for onabotulinumtoxinA will also need to checked if billed in the office setting.

Urology coding and compliance, and their continual changes, requires more than an in-house team can provide. This special expertise only happens with decades of experience from a urology coding, billing and collections industry insider, a team that understands the ins and outs of urology revenue cycle management.

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