1. Coding Conundrums

2. Copyright Acknowledgement
CPT codes and descriptions are copyright© 2011 American Medical Association. All rights reserved

3. Radiologic Documentation
Image must be kept in chart
Supervision and interpretation should be separately documented and found in patient’s chart
CPT states, “A written report signed by the interpreting physician should be considered an integral part of a radiologic procedure or interpretation.”

4. Radiology Codes
Imaging Used in the Urology Practice Fluoroscopy Fluoroscopy (separate procedure), up to 1 hour physician time, other than or (eg, cardiac fluoroscopy) Fluoroscopy, physician time, more than 1 hour, assisting a nonradiologic physician (eg, nephrostolithotomy, ERCP, bronchscopy, transbronchial biopsy)
According to CCI edits version 9.2, which went into effect July 1, 2003, fluoroscopy has been bundled into ESWL. This means for Medicare claims, modifier -59, Distinct procedural service, must be appended to code to receive reimbursement. There must be a medically necessary reason for the use of fluoroscopy apart from locating the stone for the lithotripsy.

5. Radiology Codes
Post Void Residual Urine Measurement of post-voiding residual urine and/or bladder capacity by ultrasound; non-imaging
Another source of confusion for coders is the wording of CPT® code 51798; specifically the term "non-imaging." When this CPT® code was first implemented in 2003 as a replacement for HCPCS code G0050, Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, its use was dependent on the type of ultrasound machine and the image obtained. In other words, the basis for CPT® coding was whether or not an image was obtained. The Coding and Reimbursement Committee of the AUA reviewed this issue and decided that regardless of the type of ultrasound machine used or whether an image was obtained, if the intent of the diagnostic procedure is to obtain only a post-voiding residual urine, then CPT® code is appropriate.

6. Radiology Codes Ultrasound Codes Abdomen
76700 Ultrasound, abdominal, B-scan and/or real time with image documentation; complete
76705 Ultrasound, abdominal, B-scan and/or real time with image documentation, limited (e.g., single organ, quadrant, follow-up)
A complete ultrasound examination of the abdomen consists of a B-mode scans of: the liver, gallbladder, common bile duct, pancreas, spleen, kidneys and the upper abdominal aorta and inferior vena cava including any demonstrated abdominal abnormality.
A separate written report should include comments on all these organs and elements and the findings. If particular elements cannot be visualized, the reason should be documented.
This "limited" CPT® code captures a focused examination in the assessment of one or more elements listed in the "complete" ultrasound above. If you do not visualize all the elements outlined in the "complete" description, the limited CPT® code should be used.
A separate written report should be included in the patient's chart as well as any images obtained during the ultrasonic procedure.

7. Radiology Codes Ultrasound Codes Retroperitoneum
76770 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), B-scan and/or real time with image documentation; complete
***If clinical history suggests urinary tract pathology, complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound.
76775 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), B-scan and/or real time with image documentation; limited
A complete ultrasound of the retroperitoneum consists of B-mode scans of: the kidneys, abdominal aorta, common iliac artery origins and inferior vena cava, including any demonstrated retroperitoneal abnormality. If the clinical history suggests urinary tract pathology, a complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound. Therefore, it is not appropriate to report additional ultrasound codes (such as abdominal or pelvic) for an evaluation of the kidneys and bladder.
This "limited" CPT® code captures a focused examination in the assessment of one or more elements listed in the "complete." If all of the specified elements outlined in the "complete" description are not visualized by ultrasound and documented, then the "limited" CPT® code should be used. A separate, final written report should be included in the patient's chart as well as any images obtained during the ultrasonic procedure.

8. Radiology Codes
Ultrasound Codes Pelvis Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation; complete Ultrasound, pelvic (nonobstetric), B-Scan and/or real time with image documentation; limited or follow-up (e.g., for follicles)
Pelvic ultrasound codes are used for both female and male anatomy.
Elements of a complete female pelvic examination include a description and measurement of the uterus and adnexal structures, endometrium, bladder, and of any pelvic pathology (e.g., ovarian cysts, uterine leiomyomata, free pelvic fluid).
Elements of a complete male pelvic examination include the evaluation and measurement (when applicable) of the urinary bladder, prostate and seminal vesicles to the extent they are visualized transabdominally, and any pelvic pathology (e.g., bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess).
A separate written report should comment on all the findings of these organs. If particular elements cannot be visualized, the reason should be documented.
This "limited" CPT® code captures a focused examination in the assessment of one or more elements listed in the "complete" pelvic ultrasound CPT® code It also captures the reevaluation of one or more pelvic abnormalities previously demonstrated on ultrasound. A separate written report should be dictated and included in the patient's medical chart.
This code should be selected if the urinary bladder alone (not including the kidneys) is imaged (B-scan and/or real time). Do not use CPT® code If post-voiding residual urine is obtained and the imaging of the bladder is obtained but not medically necessary, use CPT® code as discussed above.

9. Radiology Codes
Computed Tomography (CT) Studies Computed tomography guidance for placement of radiation therapy fields (For placement of interstitial device(s) for radiation therapy guidance, prostate, use 55876)

10. Radiology Codes
Dual energy X-ray absorptiometry (DXA), is a means of measuring bone mineral density (BMD). Two X-ray beams with differing energy levels are aimed at the patient's bones. When soft tissue absorption is subtracted out, the BMD can be determined from the absorption of each beam by bone. Dual energy X-ray absorptiometry is the most widely used and most thoroughly studied bone density measurement technology.
In urology, many physicians will recommend that prostate cancer patients receiving androgen deprivation therapy have a DXA scan. Medicare has established a national coverage determination for bone density studies. Be sure to check you states LCD for approved diagnosis codes.

11. Radiology Codes Dual-energy X-ray Absorptiometry (DXA)
77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips,pelvis,spine)
77081 appendicular skeleton (peripheral) (eg, radius, wrist, heel)
77082 vertebral fracture assessment
(for dual energy x-ray absorptiometry [DXA] body composition study, use 76499)

12. Radiology Codes
Brachytherapy Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure) Ultrasonic guidance for interstitial radioelement application Placement Radioactive seeds
Prior to brachytherapy treatment, a prostate volume study is performed taking 5 mm cuts or pictures to plan where the radioactive seeds are to be placed in the prostate. This study aids the radiotherapist in the placement of the seeds into the catheters or needles for placement in the prostate.
A separate report for this diagnostic evaluation is required that documents the size and volume of the prostate for treatment planning prior to the actual brachytherapy treatment. A formal report is signed by the physician and included in the patient's chart.
This CPT® code captures the ultrasonic guidance necessary to implant the radioactive seeds for brachytherapy treatment.
It is also appropriate to include a final written report on the ultrasonic guidance procedure. This report may be either separately documented or included within the report of the procedure for which the guidance is necessary.

13. Fiducial Markers in an Office
Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple
A4648 Tissue marker, implantable, any type, each
76942 Ultrasonic guidance for needle placement (e.g., Biopsy, aspiration injection, localization device), imaging supervision and interpretation
77002 Fluoroscopic guidance for needle placement(e.g., biopsy, aspiration, injection, localization device) Some carriers may bundle the fluoroscopic guidance

14. Fiducial Markers in an Office
Implantable markers, A4648, should be reimbursed
CPT states, “Report supply of device separately.”
If you are receiving denials contact your Medicare Contractor
AUA has created Gold Seed Marker appeal letter

15. PNBx
55700 – Biopsy prostate Ultrasound, transrectal Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation
It is the standard of care to perform a sonographic evaluation of the prostate for any abnormality prior to a prostate biopsy. These abnormalities will be shown as hypoechoic areas or lesions that need further diagnostic investigation. This sonographic evaluation determines whether the physician should continue with prostate biopsy. A separate report for this diagnostic evaluation is required. This formal report should be signed by the physician and included in the patient's chart
In a hospital setting, when a urologist and a radiologist perform the prostate biopsy procedure together, the urologist reports CPT® code and the radiologist reports CPT® code If the urologist performs the CPT® code 76872, Ultrasound, transrectal, then he should append modifier -26, Professional Component. If the radiologist performs the transrectal ultrasound prior to the ultrasonically guided prostate biopsy, then the radiologist would bill using CPT® code
It is also important to include a written report on the ultrasonic guidance procedure. This report may be either separately documented or included within the report of the procedure.

16. PNBX Saturation Biopsy
55706 Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance
(Do not report in conjunction with 55700)
Transperineal approach only
Can only performed in hospital inpatient, hospital outpatient or ambulatory surgical setting(ASC)

17. PNBx
G0416 Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 1-20 specimens
G0417 Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, specimens
G0418 Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, specimens
G0419 Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, greater than 60 specimens

18. Bill for all services - (select 1)
Urodynamics Test
Bill for all services - (select 1)
51726 Complex cystometrogram
51727 CMG; with urethral pressure profile studies(UPP)
51728 CMG; with voiding pressure studies(VP)
51729 CMG; with UPP & VP
AUA Coding Seminar Series 2009 36

19. Urodynamics (con’t) 51741 Complex uroflowmetry
51784 Electromyography studies (EMG) (other than needle)
51797 * intra-abdominal voiding pressure *(Add-on Code)
Can add one or all 37

20. Fluoro/Videourodynamics (FUDS, VUDS)
Urethrocystography, voiding, radiological supervision and interpretation
Injection procedure for cystography or voiding urethrocystography

21. “Incident” to Billing Urodynamics
Urologist that performs test or is in the office when performed Charges -TC
Urologist that interprets Charges 38

22. Incontinence Rx Pelvic Floor Rehabilitation 90911 Biofeedback
90732 electrical stimulation
PTNS (2011)
97014 – Unattended code for electrical stimulation – may or may not pay
G0283 – unattended code for electrical stimulation - Medicare
Caution
51784 EMG Study baseline beginning and end
97750 Functional testing (not recommended)

23. Interstim
Test Stimulation (PNE Placement)
64561 Percutaneous implantation of neurostimulator electrodes sacral nerve (transforaminal placement)
64581 Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement)
These codes represent the testing phase. If performed bilaterally, append modifier 22 to the
During the testing phase fluoroscopy is not billed out separately, this is included in the RVU’s of the code.
The testing stage has been FDA approved for the to be used first, if no improvement noted, then the may be used for the testing stage.
If the test is proven inconclusive using the percutaneous leads, then the incision for implantation of the neurostimulator electrode can be performed for the test stimulation.

24. InterStim
Permanent SNS Implantation
64581 Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement)
64590 Insertion or replacement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
Once the testing phase has been completed and the pt has a documented 50% improvement in their voiding symptoms, then the permanent leads and generator can be planted into the pt’s sacral nerve.

25. InterStim
Fluoroscopy Codes for SNS Implantation
76000 Fluoroscopy [separate procedure], up to 1 hour physician time OR
77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)
In the implantation of SNS, flouroscopy is used to appropriately place the electrodes and can be billed out separatley

26. Interstim Programming
95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impendence and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without programming
95971 simple spinal cord, or peripheral (ie, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming

27. InterStim Programming
95972 complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator /transmitter, with intraoperative or subsequent programming, first hour
95973 complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)

28. InterStim Revision/Removal
64585 Revision or removal of peripheral neurostimulator electrodes
64595 Revision or removal of peripheral neurostimulator pulse generator or receiver
Occasinally, a problem may occur with the neurostimulator electrodes or pulse generator and iether one or both of these devices may have to be removed or replaced. Infections may occur or the devices may malfunction that may necessitate the removal of the equipment.

29. Other issues
55866 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed
Nodes(?)
38571 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy
patient who had a cystectomy with ileal conduit is now having problems, which require the physician to visualize the conduit. Is there a code for an endoscopy through a stoma into the ileal loop?

30. Other issues TURBT, Fulguration, With Biopsy
52214 Fulguration, Minor, Small , Medium, Large
52204 Biopsy
patient who had a cystectomy with ileal conduit is now having problems, which require the physician to visualize the conduit. Is there a code for an endoscopy through a stoma into the ileal loop?

31. Other issues 52000 Cystourethroscopy (separate procedure) vs.
55281 Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female
patient who had a cystectomy with ileal conduit is now having problems, which require the physician to visualize the conduit. Is there a code for an endoscopy through a stoma into the ileal loop?

32. Other issues Multiple Stones
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)
52352 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)
patient who had a cystectomy with ileal conduit is now having problems, which require the physician to visualize the conduit. Is there a code for an endoscopy through a stoma into the ileal loop?

33. Other issues
44380 Ileoscopy, through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) for the visualization of the conduit.
44312, Revision of ileostomy; simple (release of superficial scar) (separate procedure) or 44314, Revision of ileostomy; complicated (reconstruction in-depth) (separate procedure).
patient who had a cystectomy with ileal conduit is now having problems, which require the physician to visualize the conduit. Is there a code for an endoscopy through a stoma into the ileal loop?

34. Other Issues
44383 Ileoscopy, through stoma; with transendoscopic stent placement (include predilation) for the ileal conduit
. For stent insertion into a continent diversion, use CPT® code Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) with a 22 modifier since there is no specific CPT® code for the stent insertion in this situation

35. Other Issues
Q Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

36. Q and A