No code for 'radical' cystectomy, but you can be paid

Q: One of our urologists performed a radical cystectomy with continent diversion and a lymphadenectomy on a "Mr. Smith." How do I charge? I cannot find the code for a radical cystectomy.

Because "Mr. Smith" is a man, the doctor probably removed his prostate (often the case with a radical cystectomy). If the prostate was removed along with the bladder and this was appropriately recorded in the operative note, then it would be appropriate to charge for a prostatectomy as well: 55840 (Prostatectomy, retropubic radical, with or without nerve sparing). If the node dissection performed is equivalent to the lymphadenectomy included in the prostatectomy description of code 55845 (Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes), the proper reporting of the service would be 51596 and 55845 only; the lymphadenectomy code would not be separately charged.

Q: We have had difficulty with reimbursement from CMS for DEXA scans in hypogonadal men. There is ample literature attesting to the accelerated bone loss in hypogonadal men and use of DEXA scans to assess for osteoporosis. However, when we order a DEXA scan with the code for hypogonadism (testicular failure), 257.2, CMS refuses to pay. Also, there seems to be an acceptable code for bilateral orchiectomy in men: V45.77 (acquired absence of the genital organs). I assume this represents outdated thinking by CMS that osteoporosis is a disease of women only, and that they are unaware of newer data and recommendations on the evaluation of hypogonadism. Is there any way to educate CMS on this issue?

A: The answer is somewhat complicated, as there are both screening services under dual-energy x-ray absorptiometry (DEXA) scans as well as medically necessary services that can be covered. The coverage under Medicare is restricted, which is addressed in Title IV of the Balanced Budget Act (BBA) of 1997, Section 4106. This section includes language providing for Medicare coverage of bone mass measurements and coverage of FDA-approved bone mass measurement techniques and equipment for "qualified" individuals. These procedures are only covered when medically necessary.

Each carrier has some flexibility in determining what "medically necessary" entails. Currently, almost all carrier coverage indications are the same, limiting coverage every 2 years for medically necessary screening (primarily of postmenopausal women with other risk factors). However, carriers can allow more frequent services if medically necessary.

Your best approach at this time would be to provide clear medical literature support when approaching the carrier medical director through your Carrier Advisory Committee representative. However, given the current coverage coherence among carriers and the national payment directive in the BBA, support from medical literature would have to be very strong to change a policy.

Disclaimer: The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRS Urology SC in Denver.