 is compliance officer and medical director of coding and reimbursement, United Urology Group and Chesapeake Urology, in Towson, Maryland.

Jonathan Rubenstein, MD

Current Procedure Terminology (CPT) codes are continuously being updated. New and updated Category I and III codes will become active on January 1, 2022. In addition, some other Category III codes may be released on July 1 of the calendar year, prior to the release of the new CPT code book. For a discussion about how to report Category III codes, please see our previous article on this subject.

 Here are new and updated CPT codes that may be of interest to urologists.

Category I codes: periurethral balloon continence device procedures (53451, 53452, 53453, 53454

 periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance. (Do not report 53451 in conjunction with 52000, 53452, 53453, 53454, or 76000.)

unilateral insertion, including cystourethroscopy and imaging guidance. (Do not report 53452 in conjunction with 52000, 53451, 53453, 53454, or 76000.)

removal, each balloon. Do not report 53453 in conjunction with 53451, 53452, or 53454.

percutaneous adjustment of balloon(s) fluid volume. (Report only once per patient encounter. Do not report 53454 in conjunction with 53451, 53452, or 53453.)

 The new year will bring 4 new Category I CPT codes that describe the insertion, removal, or fluid adjustment of periurethral balloon continence devices. These 4 codes will replace Category III codes 0548T, 0549T, 0550T, and 0551T, which are currently used to report these procedures. The reason for the change was that the maturation of data and use of these procedures met the American Medical Association’s criteria to achieve a Category I status. It is important to be aware of the code change and use the new codes to report these procedures starting January 1. The 4 codes include descriptions of the work of the code along with the exclusions and reporting instructions, which are listed in the associated parentheticals beneath each code.

Category I: Wording change for hypospadias repair codes (54340, 54344, 54348, 54352)

repair of hypospadias complication(s) (eg, fistula, stricture, diverticula); by closure, incision, or excision, simple

requiring mobilization of skin flaps and urethroplasty with flap or patch graft

 requiring extensive dissection and urethroplasty with flap, patch, or tubed graft, including urinary diversion, when performed

revision of prior hypospadias repair requiring extensive dissection and excision of previously constructed structures including re-release of chordee and reconstruction of urethra and skin brought in as flaps or grafts. (Do not report 54352 in conjunction with 15275, 15574, 15740, 53235, 53410, 54300, 54336, 54340, 54344, 54348, or 54360.)

 CPT code 53452 describes a revision of prior hypospadias repair of ultimate complexity that requires work above that of a flap, patch, or graft but also including excision of previously constructed structures. The code is mainly an editorial change because the previously used code had an outdated term that could be interpreted as offensive. The new terminology also more accurately describes the work performed.

Category III Code: Monopolar radiofrequency remodeling of the female bladder neck

 endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence

 Category III code 0672T describes a technology to treat female stress urinary incontinence with a novel dual-energy procedure, described as endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissue surrounding the female bladder neck and proximal urethra for urinary incontinence. The device itself is not yet approved by the FDA.

Category III Code: Ultrasound-guided focal laser ablation-prostate tissue

transperineal focal laser ablation of malignant prostate tissue, including transrectal imaging guidance, with magnetic resonance-fused images or other enhanced ultrasound imaging. (Do not report 0655T in conjunction with 52000, 76376, 76377, 76872, 76940, 76942, or 76998.)

 This CPT code should be used for reporting transperineal focal laser ablation of malignant prostate tissue. Imaging guidance is included and should not be reported separately.

As you update your systems and charge communication platforms for 2022, it is important to avoid using new CPT codes until they become effective on January 1, 2022. We are expecting the release of the final rule from Medicare with relative value units for the Category I codes in early November. Coverage for new codes may take some time for Medicare and other payers to develop, but all HIPAA-compliant entities are required to adopt the new CPT codes on January 1, 2022. CPT and Medicare coding conventions require reporting the most accurate code available. Private payers may require special reporting of new services if covered and are encouraged to obtain any special instructions in writing, if possible.

ICD-10 coding changes for 2022 became effective on October 1, 2021. Each office is encouraged to review the changes for ICD-10 as soon as possible for any changes relevant to its practice. All ICD-10 changes can be found in the 2022 Addendum file at the following link: https://go.cms.gov/3EYc39S.

A summary of the minor changes to ICD-10 for 2022 considered relevant to urology includes

minor changes in Excludes notes for codes N16 renal tubulointerstitial disorders in diseases classified elsewhere and N39 other disorders of urinary system

Z92.85 Personal history of cellular therapy

Z92.850 Personal history of chimeric antigen receptor T-cell therapy

Z92.858 Personal history of other cellular therapy

Z92.859 Personal history of cellular therapy, unspecified

Additional Z code changes for patient status relative to food insecurity and homelessness may be relevant to some practices but were not included as urology specific for this article.

1. Rubenstein J, Painter M. What are Category III codes, and how are they best used for billing? 

January 31, 2020. Accessed September 27, 2021. https://bit.ly/3zLtt5y

Articles

New and updated codes encompass balloon continence devices, hypospadias

Watch for these urology-related CPT codes this January

For cystoscopy with bilateral ureteral stent removal, how many unit(s) should 52310 be billed?

One unit should be billed. There are 2 codes available to report removal of a stent or foreign body: CPT codes 52310 (cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) and 52315 (cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; complicated).

CPT code 52310 describes the work of removing an indwelling ureteral stent by cystoscopy, when the stent is visualized and then grasped using a grasping instrument to remove the stent. This procedure can be performed in the office, ambulatory surgical, or hospital setting. The code requires and includes performing  a complete cystoscopy (CPT 52000), which cannot be billed separately, and therefore documentation should include the results of an examination of the urethra (such as for strictures), the prostate (in men), and the bladder (such as for mucosal lesions, neoplasms, or stones). CPT code 52310 is also the code used for simple removal of bladder stones or a bladder foreign body. Medicare has included in its rules a Medically Unlikely Edit (MUE) of 1 for this code with an indicator of 3, meaning that with medical necessity, more than 1 unit can be charged for the service but only under unique circumstances with appropriate documentation and payer review. Unfortunately, Medicare has also determined that code 52310 cannot be reported for bilateral services. 

In addition to these payment rules, the clinical description for work involved includes the possible need for multiple passes into the bladder by stating, “Reintroduce the scope and remove the next, and all subsequent, stones in similar manner, until all stones have been removed. Reintroduce the cystoscope and inspect the bladder to assure no perforations or bleeding, then empty the bladder completely and slowly withdraw the cystoscope. If appropriate, insert a urinary catheter for postoperative drainage.” Because of this wording, CPT code 52310 would be billed once even for bilateral ureteral stent removal, and no modifier should be used in an attempt to bypass the edit.

In contrast, CPT code 52315 specifically describes the complex removal of a stent. Medicare has assigned an MUE of 2 units to this code, meaning that Medicare will allow payment for this code with 2 units without record review. However, similar to code 52310, Medicare will not allow reporting of this code for bilateral services. The clinical description of this code would indicate that documentation should include the need to perform “twisting/torquing movement to try and dislodge some of the encrusted material from the stent.” Similarly, the provider may “regrasp the stent as often as necessary to try and remove the visible stone material, with the goal of atraumatically removing the stent intact from the ureter. Use fluoroscopy to monitor the progress of the stent as you slowly withdraw it from the kidney. Reintroduce the cystoscope, inspect the bladder, assure that there is efflux from that ureteral orifice, and irrigate the bladder using a Toomey syringe until all of the stone material has been removed.” This code should not be used for the removal of an encrusted stent that is easily removed, nor for the removal of bilateral stents.

When taking into account the various rules surrounding both codes, 52310 or 52315 should be reported with 1 unit for the removal of bilateral stents. However, if complex stent removal and complex stone removal are required for treatment of a patient, 52315 can be reported with 2 units.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o

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.

"When taking into account the various rules surrounding both codes, 52310 or 52315 should be reported with 1 unit for the removal of bilateral stents," write Jonathan Rubenstein, MD, and Mark Painter.

Why 1 unit should be billed for cystoscopy with bilateral ureteral stent removal

Could you tell me what the appropriate diagnosis would be when a patient goes in for surgery to have a ureteral stone (52351 and 52332) removed and a stent placed and the stone is no longer present, presumably it has already passed?

Each bill that is submitted for reimbursement must have a code for both the service performed and a reason for the service. The service performed is an HCPCS [Healthcare Common Procedure Coding System] code, either Level I or Level II. The accompanying reason is chosen from the 

In the situation described, a patient is brought to a procedure room to perform what is scheduled as a removal of a ureteral stone and a stent placed, which encompasses 52352 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with 

removal or manipulation of calculus [ureteral catheterization is included]) and 52332 (cystourethroscopy, with insertion of indwelling ureteral stent [eg, Gibbons or double-J type])or similarly for laser lithotripsy and stent placement, 52356 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent [eg, Gibbons or double-J type]) for the indication of N20.1 stone, ureter.

However, upon performance of the case, the patient was found to have passed the stone and the patient had undergone a diagnostic ureteroscopy and stent placement (CPT codes 52351, cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic and 52332, respectively). Assuming there was no other pathology found and no stone found but the patient was treated with a stent, the indication for the procedure remained unchanged. Therefore, 

 guidelines, which indicate in the absence of another, more appropriate diagnosis, the intended reason for the service should be reported even if the condition no longer presents.

"Each bill that is submitted for reimbursement must have a code for both the service performed and a reason for the service," writes Jonathan Rubenstein, MD, and Mark Painter.

How to bill for stone removal when stone is no longer present at time of procedure

Is biofeedback a billable service after a robotic radical prostatectomy during the global period?

Payment for a procedure is based on the global surgical package, which means payment includes all the services that would typically be furnished by a surgeon prior to, during, and after a procedure. For example, included in the surgical package is the typical work the day of the procedure, all additional medical or surgical services provided in a postoperative period including hospitalization, discharge from the hospital, and routine postoperative visits within the global period. Additionally, payment includes postsurgical pain management and all medical and procedural postoperative services required because of complications that do not require additional trips to the operating room, as well as follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery.

The following are not included: visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits are due to complications of the surgery; treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery; diagnostic tests and procedures, including diagnostic radiological procedures; clearly distinct surgical procedures that occur during the postoperative period that are not reoperations or treatment for complications; procedures that are more extensive because the initial procedure failed and treatment of complications that require a return to a qualified operating room.

In this case, 55866 is a 90-day global procedure. We could argue a couple of points within the definition of the global that may or may not support coverage of biofeedback during the global period: No. 1: Is the biofeedback a treatment for a complication of the procedure or treatment for an underlying condition? No. 2: Is the treatment an added course of treatment not a part of the recovery from surgery?

Outside the global payment concerns, we also have to consider that Medicare typically does not pay for preventive services unless they are specifically allowed. So we would also have the question “Is the treatment provided for an existing condition, or is the biofeedback provided to prevent a complication or condition that may occur in the future?”

The questions are moot for most of the postoperative period for Medicare patients, as the issue of coverage of biofeedback is the most common and biggest roadblock.

Medicare covers biofeedback for the treatment of stress and/or urge incontinence in cognitively intact patients when documentation supports a previously failed trial of pelvic muscle exercise (PME) training. A failed trial is observed when no significant clinical improvement in urinary incontinence is noted after completing 4 weeks of a physician-prescribed plan of PME. Medical record documentation of the failed PME trial must be present to justify coverage for biofeedback.

This coverage guideline has 2 requirements: (1) that the patient has or has received a diagnosis of stress or urge incontinence—this means your physician will need to provide a diagnosis for the patient appropriately after recovery from surgery; (2) according to the coverage guidance, Medicare will cover biofeedback only after 4 weeks of pelvic floor therapy has failed. After meeting these coverage guidelines, you will need to circle back and answer the questions surrounding the global inclusion to determine coverage.

Recall that these are Medicare coverage guidelines, so private payers may differ. And these are the current coverage guidelines, which can be changed, but rarely do these change rapidly, and they will not change without supporting data. In the long run, with appropriate proof, coverage may change. In the short term, you may be able to argue medical necessity and outcomes for coverage on a case-by-case basis with your Medicare carrier.

The answer to your question is that coverage is very unlikely as you will have to have the data (in peer-reviewed articles) and time to push for medical necessity (to override the coverage issue) and you will have to satisfy the global inclusion questions (either the patient had a pre-existing condition or the treatment is an added course of therapy not a part of the recovery from the surgery).If you do decide to challenge for reimbursement, please refer to our article from last year on this subject.1

CPT [Common Procedural Terminology] code 90911 (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) was deleted on January 1, 2020. It was replaced with 2 new time-based codes: CPT codes 90912 and 90913.

CPT code 90912’s description reads, “biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient.” By comparison, CPT code 90913 is an add-on code to “describe each additional 15 minutes” of one-on-one physician or other qualified health care professional contact with the patient. Note that CPT code 90913 must be used in conjunction with code 90912; it cannot be billed alone. Please also note that the time is based on one-on-one face-to-face time, so there should be no overlap with other patients.