Sometimes modifier 59 will rescue your reimbursement.
Just when you were getting a grasp on all 2010 coding changes, the round two of the Correct Coding Initiative (CCI) edits went into effect on April 1. This has tied the hands when coding many common urology procedures, including prostate biopsies and urethral dilations.
Heads up: The latest version covers 2,054 new active pairs and 1,947 modifier changes, as laid down by Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions Inc. in Clearwater, Fla.
Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook says, “For urology, there’ll be 78 edit pair additions and two edit pair deletions.” To see to it that you get paid right for your urologist’s services this quarter, take a look at these key changes.
Bid goodbye to biopsy with several prostrate procedures
You can no longer go for 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 inclusive of control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, as well as internal urethrotomy are covered]). Your payer will get you the pay for 52630, however, deny the biopsy codes and you can’t go for a modifier to separate these new edits.
Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind laments, “I’ve no primary issue with the bundling of 55700 and 52630.” According to Kater, her urologists carries out a good number of prostrate biopsies transrectally and 55700 is what she makes use of as the descriptor says “any approach”. When you’re carrying out two separate procedures using two different approaches, how can they be bundled?
Here’s the silver lining: CCI also bundles 55705 (Biopsy, prostate; incisional, any approach) into 52630, however the edit carries a “1” modifier indicator. As such, you can break that bundle if clinical circumstances demand separate reporting.
Moreover: With effect from April 1, transurethral resection of the prostate (TURP) code 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, thorough [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are covered]) 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”; as such you can never bill those codes together. According to Ferragamo, contrary to this, both the 52647/55706 and 52649/55706 bundles have a modifier indicator of “1”, which means you can go for the codes together under specific clinical circumstances using a modifier like modifier 59 (Distinct procedural service).
You’ll find prostate biopsy listed as 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), and Cryosurgical ablation of the prostate (55873).
The modifier indicator for all the mentioned edits is “1”. You can break the bundles when clinical circumstances warrant.