The use of technology in urology procedures – especially surgeries – has introduced many benefits: fewer complications, shorter hospital stays and recovery periods, and much smaller surgery scars. So it’s no surprise that we’ve seen a significant rise in robotic-assisted surgeries in recent years. The problem is that coding and billing updates have been slow to keep up with the trend.
The lack of a Current Procedural Terminology (CPT®) code for every robotic surgery performed has coders understandably confused, says coding consultant and professor of urology Michael Ferragamo in his live webinar on robotic surgery codes and laparoscopic CPT® codes. As part of his 4-webinar series for ProfEdOnDemand’s 2019 Coding Update Virtual Boot Camp, Ferragamo guides you through proper coding for procedures such as prostatectomies—and tells you what to do when there is no code for a certain situation.
Simple v. Radical: Tease Out the Differences
Open and robotic-assisted surgery codes can differ by only a word or two, so you’ll need to pay close attention to each word, as carelessly selecting a code that seems right can lead to claims denial or lack of reimbursement. Let’s take a quick look at two common procedures to see how you’d go about selecting the correct code.
Simple or Radical Prostatectomy?
Prostatectomy is the removal of all (radical) or part (simple) of the prostate. Both radical and simple prostatectomies can be open (surgical) or robotic-assisted. In order to bill properly, ensure your documentation contains everything you need:
Simple: Removal of only the part of the prostate that is blocking urine flow. This procedure is recommended for men with severe urinary problems and those who have enlarged prostate glands (known as benign prostatic hyperplasia, or BPH). A simple prostatectomy is not recommended for men with prostate cancer.
Radical: Removal of all of the prostate, including the seminal vesicles and vas deferens. Radical prostatectomies are recommended for men with prostate cancer. Often radical prostatectomies are accompanied by lymph node removal, as lymph nodes are typically an initial landing spot for the spread of prostate cancer.
What can be bundled: Exercise caution when bundling other services with prostatectomies. Code 51990, for example, cannot be bundled if performed as part of the overall procedure; it can be added on if it was done due to a prior urinary incontinence diagnosis. Check the documentation and ensure it mentions a prior diagnosis as well as medical necessity for codes you wish to bundle.
Modifier 52: Not for Changing Radical to Simple
Coding for prostatectomies can be especially tricky, as you’ll be tempted to cut corners to select a code for procedures that don’t yet have a code. Current CPT® prostatectomy codes are found in the 55801-55866 range – subject to change with the CPT® updates on Jan. 1, 2019 – although you’ll notice one glaring issue: There is no exact code for a simple laparoscopic prostatectomy.
If you’re tempted to one of the radical prostatectomy codes and append modifier -52, Reduced Services, you’re making a mistake. That would be an incorrect use of -52, as the modifier is not intended to change a code description or the meaning of a code. If the surgeon went in intending to perform a certain procedure and ended up performing only a part of it, then -52 would be appropriate, but in the instance of a simple prostatectomy, this is not the case.
Know When to Use ‘Unlisted,’ ‘Other,’ or a Vaguely Worded Code
How, then, do you properly code for procedures such as simple laparoscopic prostatectomies when there is no exact code for them? In his presentation, Ferragamo outlines for you when you can use an “unlisted” or “other” code, as well as when you can use a vaguely-worded code to cover a certain procedure.
Don’t let an incorrect modifier or code use put your practice at risk for compliance failure or reimbursement reduction! Such roadblocks are tricky to overcome, but not impossible with the right training and information.
