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

Jonathan Rubenstein, MD

My surgeon performed a transurethral resection of the prostate (TURP; CPT 52601), but the insurance company reduced the reimbursement because a vasectomy was not performed at the same time, and the insurer said that was part of the code. Am I missing something? Why would they do this?

We find that at times, insurers or auditors seemingly overstep their understanding of what urologists really do and deny services without an in-depth understanding of the code. That is why it is so important to review denials and payment discrepancies. This is a perfect example and we are glad that you brought this up. It is clear that the issue is due to a misinterpretation of the code and the parenthetical attached to the 

code. Depending on the age of the surgeon, one may be surprised to hear that it was common to perform a vasectomy routinely on patients undergoing a TURP procedure. From what we hear, it was performed to reduce the risk of postprocedure epididymitis. However, that is no longer the standard practice. Nonetheless, since it was commonplace at the time of the creating of the TURP CPT code, it was included in the code in a parenthetical, which was meant to describe what procedures should not be reported separately if performed at the same time. CPT code 52601 is written as follows: Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included).What many do not understand is that the parenthetical after the CPT code describe procedures that are included if they are performed, but ultimately none of the procedures listed in the parenthetical (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy) need to be performed to bill CPT 52601 without a modifier. However, if any of these procedures are performed at the time of a TURP, they should not be reported separately. Urethral meatotomy performed to get the scope in, cystoscopy itself, urethral calibration, dilation, and even direct vision internal urethrotomy are included if performed but also are not required.

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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.

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"Depending on the age of the surgeon, one may be surprised to hear that it was common to perform a vasectomy routinely on patients undergoing a TURP procedure," write Jonathan Rubenstein, MD, and Mark Painter.

TURP reimbursement denied due to misinterpretation of parenthetical attached to code

On occasion, we have a patient who presents to our office for a catheter change, and they request that we use the specific catheter that they bring in to the office, maybe due to preference. Since the cost of the catheter supply is bundled into the reimbursement for the code for Medicare, should we simply modify CPT 51702 with the –52 modifier for reduced services?

Your question is interesting and points out just one of the many issues we encounter in this complicated system. From a coding perspective, you are performing the service described regardless of who purchased the catheter for the procedure. Modifier –52 is defined by 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. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC [ambulatory surgery center] hospital outpatient use).”

From this perspective, the reporting of modifier –52 would be incorrect as the catheterization was provided as described by the CPT code.

From a payment perspective, Medicare has included the cost of a catheter when assigning the practice expense value and will therefore not allow for separate billing or payment of the catheter. Although there are a number of references within the CMS manual that block payment for supplies incident to a procedure, including catheters, there are no clear references to the circumstance you have noted. Despite this lack of reference, it is clear that if a practice were to require or encourage all or some of their patients to supply their own catheters, it would be considered a violation of your Medicare participation and could result in takebacks, fines, or even exclusion from Medicare.

If you have a patient who insists on bringing a catheter to the visit for insertion and refuses to allow insertion of the catheter offered by the practice, we do not see a policy that would prevent your practice from providing the service for the patient or changing the billing of the service. However, we would recommend that you have the patient sign a document indicating that they insisted on using their own catheter, in a format similar to an advanced beneficiary notice dated the same date the service was provided.

"It is clear that if a practice were to require or encourage all or some of their patients to supply their own catheters, it would be considered a violation of your Medicare participation and could result in takebacks, fines, or even exclusion from Medicare," write Jonathan Rubenstein, MD, and Mark Painter.

What are the reimbursement implications when a patient brings their own catheter?

Our physicians will review the results of a Sexual Health Inventory for Men (SHIM) score, an International Prostate Symptom Score (IPSS) questionnaire, and a Prostate Cancer Survivorship questionnaire. Can I count the review of these 3 tests to obtain a “moderate” level of data reviewed using the new 2021 evaluation and management (E/M) guidelines?

No. As many of you know, “moderate”-level data can be achieved by satisfying any 1 

of 3 categories within the Data section as defined in the 2021 E/M guidelines:

 Any combination of 3 from the following:

• Review of prior external note(s) from each unique source

• Review of the result(s) of each unique test

• Assessment requiring an independent historian(s)

 Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported).

 Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported).

As categories 2 and 3 are clearly not appropriate for classifying any of these questionnaires, we look to Category 1.

Under Category 1, patient questionnaires cannot be considered “review of prior external note(s) from each unique source.” The questionnaires meet neither the definition of external note nor of unique source as defined by Current Procedural Terminology (CPT) below:

“A unique source is defined as a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity”; and

“External records, communications and/or test results are from an external physician, other qualified health care professional, facility, or health care organization.”

Questionnaires cannot be considered tests under these guidelines, as tests are defined by CPT as “imaging, laboratory, psychometric, or physiologic data,” and they are further defined within the guidelines as services designated by CPT codes, with the differentiation between a single or multiple unique tests being defined in accordance with the CPT code set.

Finally, these questionnaires are typically provided to and answered by the patient, and therefore they cannot not be considered an assessment by an independent historian.

Therefore, questionnaires, including the SHIM, IPSS, and Prostate Cancer Survivorship Questionnaire, no matter how useful, are not considered data points under the new guidelines. The only exceptions would be if the patient’s overall history was provided by an independent historian or if the information was gleaned from review of another physician’s record which, in either case, would result in only 1 data category.

SHIM and other questionnaires do not satisfy categories within Data section.

Questionnaires are not counted as tests under new E/M coding guidelines

I am wondering if code 38571-52 would be appropriate in the following scenario at the time of a robot-assisted laparoscopic prostatectomy:Patient is noted to have a paucity of lymph node tissue overlying the left iliac vein and obturator nerve. Right-sided pelvic lymph node dissection was then performed with the margins being the pelvic sidewall, obturator nerve, and iliac vein. Proximal and distal ends of the lymph node packets were ligated with hemo lock clips and transected with electrocautery. Specimen was then sent out as right pelvic/obturators lymph node package. This was performed at the time of a robot-assisted laparoscopic prostatectomy.Or, would we need to use unlisted code 38589 and compare it to 38562 approximately? And do you have another comparable code for reimbursement comparison if I need to use unlisted code 38589 and code 38562 is not close enough?

Common Procedural Terminology (CPT) code 38571 describes 

Laparoscopy, surgical: with bilateral total pelvic lymphadenectomy

Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic.

 The work of performing CPT code 38571 includes the removal of the total lymph node packet from both sides of the pelvis. In the case described above, a complete lymph node packet was removed from 1 side of the pelvis only. When reviewing the 2 options you describe, it would be most appropriate to bill CPT code 38571 and to append modifier –52 

to the code. That describes the service performed more accurately than a limited pelvic lymph node dissection, as it describes the completeness of the lymph node dissection and approach 

(laparoscopic), albeit just the 1 side. The option of the unlisted laparoscopic code 38589, as you noted, is also a valid choice, referencing the reduced value of 38571. Either way the service is reported, the payer should require documentation be submitted for review prior to payment, and the use of the –52 on the 38571 will provide more appropriate guidance for reimbursement processing.

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

 is CEO of PRS Urology SC in Denver, Colorado.

"Either way the service is reported, the payer should require documentation be submitted for review prior to payment, and the use of the –52 on the 38571 will provide more appropriate guidance for reimbursement processing," write Jonathan Rubenstein, MD, and Mark Painter.

Jonathan Rubenstein, MD

Articles

TURP reimbursement denied due to misinterpretation of parenthetical attached to code

What are the reimbursement implications when a patient brings their own catheter?

Questionnaires are not counted as tests under new E/M coding guidelines

Why CPT 38571 plus modifier 52 is recommended in this RALP case