Ray Painter, MD
One of my colleagues tells me that he is billing a urethral suspension at the same time he does his laparoscopic radical prostatectomy and is getting paid by Medicare. That seemed too good to be true since a suspension could be performed on every patient. Is it OK to bill a suspension with a radical prostatectomy?
Good question. Unfortunately, it deserves several answers. According to the National Correct Coding Initiative (NCCI), Medicare’s bundling edits, the two codes (55866 - Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed) and 51990 (Laparoscopy, surgical; urethral suspension for stress incontinence) are not bundled and can be charged together without a modifier.
However, we have several concerns about billing for the urethral suspension at the same time you perform a radical prostatectomy in a patient who did not have a preoperative incontinence problem necessitating the suspension. First and foremost, by law, Medicare cannot pay for preventive services unless specifically enacted by Congress. That means Medicare could ask for their money at a future date if a record review resulted in the determination that the service was not medically necessary at the time the service was performed.
The AUA has also reviewed this issue and indicated in a Policy and Advocacy Brief published May 3, 2017 that reporting the suspension with a prostatectomy should be reserved for those patients with an existing diagnosis of incontinence.
Also by the Painters: Medicare proposed rule outlines significant changes
Considering both the current policy interpretation risk and the AUA position, we feel it’s important to highlight the concern for future bundling edits. If a high percentage of the radicals are billed with urethral suspension, then it is likely to be bundled in the future and it is possible that it will be tagged with an indicator that will not allow unbundling, closing the door on appropriate billing for those patients with existing incontinence.
Consider this similar situation: Initially, 51800 (Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck [anterior Y-plasty, vesical fundus resection], any procedure, with or without wedge resection of posterior vesical neck) was not bundled with 55845 (Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes), and many physicians were billing the two together. Currently, they are bundled and cannot be unbundled.
In summary, yes, the two procedures can be billed and should be paid. However, we recommend you do not bill, unless the patient has incontinence and the need for the suspension prior to surgery.