Diligence needed to outwit the Medicare computers

A. For a review of the original article describing this scenario, please see: https://www.urologytimes.com/view/endoscopy-procedures-fall-under-surgical-codes

The CCI edits reflect the way the Medicare computer has been programmed and the way you will be paid when you submit your claim. However, if there is another rule that states that you should be paid, such as, "If a diagnostic test (the retrograde) leads to the decision to provide a therapeutic procedure, such as the insertion of a stent, breaking up a stone, etc., then the diagnostic retrograde should be paid separately." As mentioned, you will be denied by the computer, but with an appeal and the proper documentation, you should be paid.

Q. I work in a urogynecology practice, and my physicians are billing for a diagnostic cysto at the same time as a transvaginal tape procedure for stress urinary incontinence. They are billing the TVT procedure and then, following this procedure, they are billing for the cystourethro-scopy with the diagnosis of urgency and frequency. Medicare is denying all of these claims, and we are starting to see denials from other carriers as well. Any suggestions?

A. The cystoscopy is bundled into the TVT (57288: sling operation for stress incontinence, such as fascia or synthetic). If the cystoscopy is being done to check the anatomy prior, during, or after the procedure to be sure everything is as suspected or to make sure there are no sutures in the urethra, then the cysto is being done to facilitate the procedure and should not be charged.

Medicare has assumed that all your diagnostic studies have been performed prior to you subjecting the patient to a surgical procedure such as the sling placement.

However, if you are performing a diagnostic cysto for a totally different reason, such as surveillance in a patient with a history of bladder tumors, then you should charge the cysto with the -59 modifier and appeal once you have been denied payment. Again, once you provide the information to Medicare that indicates this was a diagnostic procedure performed for a totally different reason, it should be paid.

Q. My physician attended a seminar and was told we could bill a photoselective vaporization of the prostate, 52647/52648, with instillation of Novocain in the bladder, 51700, and pudendal nerve block, 64430. According to CCI edits, 51700 is incident to 52647 or 52648. What are your suggestions for this?

A. The local anesthetic is included in the CPT "package" for a procedure. Medicare has adopted this concept. The local instillation of procaine hydrochloride (Novocain) into the bladder area would be considered a part of the procedure, and the instillation procedure should not be charged separately. A regional anesthetic is paid separately in some cases. If your physician is truly doing a pudendal nerve block, then there is an argument for charging the 64430 separately and, if charged, you should be paid.

Medicare has made the decision that you should not charge separately for the nerve block code in addition to a prostate needle biopsy. Also, in your CCI edits, CMS has bundled a number of injection codes into the procedure, most of which are ridiculous. However, CMS does not have the 64430 bundled.