UroCuff coding presents a “conundrum” for billers

We have a question about coding and reporting the UroCuff procedure. Some recommend reporting it with Current Procedural Terminology (CPT) code 51728 with modifier –52 (reduced services), whereas others recommend using CPT code 55899 (Unlisted procedure, male genital system). What are your thoughts on this conundrum?

Jonathan Rubenstein, MD

The UroCuff test is a noninvasive (no indwelling catheter) natural fill bladder pressure test. Currently, there is no CPT nor Healthcare Common Procedure Coding System code that specifically describes the UroCuff test. This lack of a specific code to report this service can be a burden to both the payer and the provider. Therefore, if this test is considered medically necessary and as such covered by a payer, the path to correct and efficient adjudication may be different for each payer.

Following is a discussion of each option.

Mark Painter

51728-52. Code 51728 (Complex cystometrogram [ie, calibrated electronic equipment]; with voiding pressure studies [ie, bladder voiding profile], any technique)includes both the complex cystometrogram (CMG) and a voiding pressure study. The UroCuff procedure measures bladder voiding pressure but does not provide measurements for the complex CMG. Modifier –52 is defined in CPT as follows: “Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier –52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.”

Based on the modifier definition, appending the modifier –52 to the 51728 would signify to the payer that a portion of the procedure has been eliminated at the discretion of the physician. Specifically, the physician has elected to perform a voiding pressure study, any technique without a concomitant CMG.

This method of reporting may be preferred by some payers, as it allows for processing of those claims under existing contract and coverage terms and appears to conform with the intended use of the modifier and CPT code and previous instructions.

Unlisted code 53899 or 55899. In their Coding and Advocacy Brief posted on 05-03-2017, the American Urological Association (AUA) examined the UroCuff and issued the following statement: “The Committee determined that 51728-52 is not appropriate to report the voiding pressure study. At this time, the Committee is unaware of a CPT code available to report using a penile pressure cuff for a urethral pressure study. If there are questions, please contact your insurer for possible alternative CPT reporting. If an alternative CPT code or set of codes is agreed upon, we recommend that the agreement is put in writing.”1 (note: link no longer active)

The opinion of the AUA, a premier urologic association, is given significant weight by payers when considering the best way to adjudicate claims. Therefore, payers may require reporting of UroCuff under code 53899 (Unlisted procedure, urinary system) or code 55899 (Unlisted procedure, male genital system).

Medicare and other payers will likely require medical record review regardless of whether you choose to report the voiding pressure study with an unlisted code (53899/55899) or 51728-52, until a coverage policy has been adopted by the payer. Multiple Medicare carriers have issued local coverage articles (LCAs) for some states that direct the use of 55899 with specific verbiage in Box 19 for reporting the UroCuff test. One carrier also included a reimbursement rate in the LCA.

It should be noted as well that regardless of the choice of code 51728-52 or 53899 or 55899, reporting the service will require that Box 19 in the claim form be populated. In these cases, it is recommended that an office use consistent verbiage in Box 19. A payer may use the combination of codes and Box 19 verbiage to develop an adjudication pathway, pricing, and coverage that does not require manual processing and record review for every case.

Given the above background, when determining which code you should use, you must consider your Medicare carrier’s published rules and commercial payer processing policies. Successful urology practices will often establish an internal reporting for UroCuff and assign the revenue cycle management charge release team or, through a series of programmed rules, payer-specific billing protocols. It is imperative to frequently check with the payer regarding reporting and coverage for the UroCuff test as recommended for any other service rendered. Obtain the directions for reporting the UroCuff test in writing, where possible.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. 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.