How to select a code for stone removal procedures

One of our urologists billed out a 52318 for a litholapaxy. The operative report reads: “It is estimated there are approximately seven to eight stones total. Most stones measure approximately 1.5 to 2 cm in size in maximum dimension. The remainder of the bladder appears normal.” When questioning the physician about billing 52317, rather than 52318, he replied: “As far as I know, it is always based on overall or total stone burden. Treating several 2-cm stones to equal a total stone burden of 6 cm is different and requires more work, more OR time, etc. than treating a single stone of 2 cm. I have never seen any reference stating measurement is based on the single largest stone. Also refer to percutaneous nephrolithotomy codes 50080 and 50081. Same thing. If you treat multiple 2-cm stones in the kidney, that would be billed as 50081, as total stone burden is over 2.5 cm.” Would you offer an opinion or any references for this situation?

Thank you for your question. Based on terminology in CPT and clarifying notes from the CPT Assistant newsletter, you have actually raised two different issues requiring separate answers.

First, let’s look at the situation you have identified with bladder stones treated with litholapaxy. The codes you have identified read as follows:

• 52317 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (<2.5 cm)

• 52318 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (>2.5 cm)

As the codes include an “or” statement after the semicolon, we can treat the descriptions of each service as only looking at “simple” or “complex” and ignore the reference to size. In this approach, the physician interpretation and documentation determines whether the service provided was complex due to multiple stones, anatomy, or other complicating factor or whether the procedure was simple regardless of number of stones or anatomy. I believe this is the case for your example, and 52318 would be appropriate.

However, if the codes did not have the “or” in the descriptions and you only had the option to choose the correct code relative to size of stone-either small (<2.5 cm) or large (>2.5 cm)-our answer would be different, which brings us to the second part of your question concerning percutaneous nephrolithotomy.

An FAQ in the June 2009 CPT Assistant has clearly indicated that the size noted in the description of code 50080 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm) and 50081 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm) is intended to reflect the largest stone removed. Further, this FAQ clearly indicates that the number of stones and cumulative size is not relevant to code selection for these codes and extends this logic to other codes that include a reference to size.

In other words, CPT has indicated that the size of the largest stone should drive code selection for codes 50080 or 50081. Your question also points out the importance of understanding each description as you select the appropriate code for services provided. Continue to next page for further questions and answers.

I have heard there is a change to the 1500 form for billing. Is this true, and what does this mean?

What you have heard is correct. The CMS 1500 (aka HCFA 1500 form) has been revised, and payers including Medicare have been directed to accept the new 02/12 1500 form. Most payers were capable of accepting the new form in January of this year. Medicare has established the following time frame:

• Jan. 6, 2014: Medicare begins receiving and processing paper claims submitted on the revised CMS 1500 claim form (version 02/12).

• Jan. 6 through March 31, 2014: Dual-use period during which Medicare continues to receive and process paper claims submitted on the old CMS 1500 claim form (version 08/05).

• April 1, 2014: Medicare receives and processes paper claims submitted only on the revised CMS 1500 claim form (version 02/12).

The paper claim form, which is maintained by the National Uniform Claim Committee (NUCC), was updated to keep pace with changes that were made to the 837P electronic claim form in anticipation of the switch from ICD-9 to ICD-10. This update and the ruling by the NUCC actually apply to all payers affected by HIPAA. Although most claims are processed electronically, there are times the claim is sent via paper for a variety of reasons. You will need to check with each of your payers to determine whether they are going to comply with this requirement in accordance with the timeline above.

Although the primary focus of the change in form was to accommodate the shift to ICD-10, the form underwent a number of other changes. Space does not allow us to discuss all the changes here; if you are interested in further information, please visit: www.nucc.org/images/stories/PDF/understanding_the_changes_to_the_0212_1500_claim_form.pdf

In order to comply with this change, you will need to double check with your practice management vendor. From a supply standpoint, avoid ordering 08/05 1500 forms unless they are required by specific payers that you frequently bill on paper.

In a previous column (“Nephrostomy tube removal: How to code,” Nov. 2012), a question was submitted regarding billing for antibodies on prostate biopsy specimens. I am a solo practitioner and do not own or belong to a pathology lab. Am I correct in assuming that the party who submitted the question owns a pathology lab as part of his practice and therefore can bill for the antibodies?

Yes, you are correct in your assumption. You cannot bill for the service discussed unless you own the lab that is providing that service. Conversely, the antibody issue does not affect the appropriate reporting of Prostate biopsy.

National Correct Coding Initiative (CCI) edits appear to bundle 51720 when coded with 52234-52240 (transurethral resection of a bladder tumor). Our physicians frequently instill mitomycin after the resection for our day surgery patients. The American Hospital Association coding clinic for Healthcare Common Procedure Coding System indicates this is appropriate. But this doesn’t seem to meet the Medicare definition of separate site, lesion, injury, or encounter. Is modifier –59 appropriate?

You have noted correctly the bundling issues as they exist in the CCI. We feel that the use of the –59 is appropriate for these cases. The instillation of the mitomycin or another anticarcinogenic drug following a TURBT is provided to patients as ongoing treatment of the disease and not a part of the excision of the tumor per se, and you should be paid separately from that procedure.

We have also noted that many physicians wait to instill the anticarcinogenic drug until they are in the recovery room. If that’s the case, the different “encounter” definition has been met.

In either case, this is another instance where the CCI has pursued a payment policy that is inconsistent with treatment and/or proper coding in the interest of saving Medicare a few cents. Expect more of these bundling pairs to appear in the CCI. We would encourage each of you to write to the AUA or directly to CCI with clear reasoning as to why in fact code pairings like this should not be included in CCI.

With the number of issues faced by urology today with health care reform, implementation of ICD-10, code bundling, and value changes, the AUA has its hands full, and all urologists will need to get involved in changing the rules to help protect patient treatment. Get in the game; if you do not protest, you will be restricted.UT

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