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

Jonathan Rubenstein, MD

I am a coder and have a question regarding the use of Current Procedural Terminology (CPT) code 55650, billed during a laparoscopic robotic prostatectomy. I have one urologist who consistently bills CPT codes 55866, 38571, and also 55650-50 for this procedure, and whose documentation describes removing the seminal vesicles along with the prostate and lymph node packets. However, I have another urologist who only reports CPT 55866 and 38571 for the same work, including removal of the seminal vesicles. So I’m wondering if the seminal vesiculectomy is sort of “built in” to the prostatectomy CPT code.

You are correct: Seminal vesiculectomy is sort of built in to that code. To understand why, we need to learn how codes are valued.

Per the American Medical Association (AMA):

"Once new codes are created, or older codes are updated, the Centers for Medicare & Medicaid Services (CMS) assigns a value to each code, which determines the payments for that particular service under Medicare. To make sure physicians have a say in this process, the AMA created the Relative Value Scale Update Committee (RUC), a volunteer group of 31 physicians and health care professionals with input from 300 health care experts that represent each sector of medicine. Specialty societies survey their members and make recommendations to the RUC based on their areas of expertise."

When a code is presented to be valued, a vignette is created that describes the typical procedure that is performed. That vignette is included in the survey. The survey responses are then reported to the RUC.

So for a CPT code such as 55866 (laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed), it is typical to remove the seminal vesicles as part of the procedure. We need to remember that the concept of performing any “radical” procedure includes the surgical removal of the organ and the surrounding or attached structures and tissues (think radical nephrectomy). There would be no medical necessity otherwise to remove the seminal vesicles, and therefore removal cannot be reported separately.

As you note, lymph node dissection CPT 38571 (laparoscopy, surgical; with bilateral total pelvic lymphadenectomy) would be reported if performed, as the pelvic lymph nodes are not directly surrounding the prostate or part of the typical surgical removal of the gland.

CPT 55650 describes “vesiculectomy, any approach” and would be reported with modifier 50 for bilateral removal of both seminal vesicles for those cases in which the vesiculectomy is provided during an encounter that did not include a separate service that included the removal of the seminal vesicles. However, again, this would not be reported separately at the time of radical prostatectomy for the reasons described above, but reported only as a stand-alone procedure for removing the seminal vesicle(s) for a specific reason or pathology or for a medically necessary reason at the time of an unrelated service.

1. Lifecycle of a code: how the CPT and RUC process works. American Medical Association. March 19, 2014. Accessed August 31, 2022. https://bit.ly/3R6Vxdl

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.

Articles

For CPT 55866, it is typical to remove the seminal vesicles as part of procedure.

Is seminal vesiculectomy included within the prostatectomy code?

On July 7, 2022, the Centers for Medicare & Medicaid Services (CMS) released the calendar year 2023 Medicare Physician Fee Schedule (MPFS) proposed rule. This outlines the proposed updates for payment and policy starting January 1, 2023. As always, there is a comment period, after which CMS must respond and react to each comment received.

What follows are some of the most notable areas of interest to urologist and urology practices.

The conversion factor for 2023 is set to decrease by approximately 4.4% from $34.6026 to $33.0775. The decrease is due to the expiration of a 1-year 3% increase that was enacted by law last year coupled with a mandated 0% increase.

 CMS is changing the update process for clinical labor included in the calculation of the practice expense component within the MPFS. We are currently in the second year of this change. Medicare has indicated that it is continuing to examine the process it is using to increase the transparency and consistency of this update moving forward.

Medicare is updating the malpractice component of the fee schedule as well. Urology is projected to face a 1% decrease in Medicare payments related to these changes. The impact to group practices and the individual physicians, however, varies based on practice type and mix of patients and services provided to those patients. Note: The impact of relative value unit (RVU) changes is independent of the conversion factor change noted above.

 Of particular interest to specialists such as urologists, CMS is seeking comment on “improving” payment for the global surgical package and seeking comment on strategies that will make global surgical payment “fair and equitable.”

Evaluation and management (E/M) services revisions for hospital inpatient and observation services and outpatient consultation services:

 CMS is proposing to adopt nearly all the revisions for Current Procedural Terminology (CPT) codes used to report E/M visits, including inpatient and observation hospital services. The changes include revisions to the documentation guidelines and to the descriptors, which will mirror the revisions previously made to the Office or Other Outpatient E/M services in 2021. Inpatient E/M code level may be chosen based on time or medical decision-making; like office and other outpatient codes, documentation for patient history and exam sections needs to be medically appropriate but is no longer used to determine code level. In addition to hospital inpatient and observation services, the update will include emergency department, nursing facility, home or residence services, and cognitive impairment assessment services. (Outpatient and inpatient consultation services will also be updated, although these services are not recognized by Medicare.) As part of the expansion of these guidelines, there will no longer be unique codes for inpatient and observation unit codes, but rather, the observation codes will be eliminated and the descriptor for the previous inpatient hospital codes will now describe hospital or observation services (initial, subsequent, discharge, and admit/discharge).

There will be a number of small adjustments to RVUs in urology only, but the codes listed in 

 will see changes greater than 5% up or down for 2023.

 CPT codes 50080 and 50081 are undergoing a description change that has resulted in the changes noted in Table 1. Code 558XX is a new CPT code for laparoscopic simple prostatectomy, which has affected the value of the other prostatectomy codes listed in Table 1.

CMS has proposed to delay until 2024 the change requiring split/shared services policy to be determined solely by the qualified health professional (QHP) spending the most time with the patient on the date of service. Current CMS rules allow that the QHP documenting the most substantive portion of a visit, history, physical exam, or medical decision-making or determined by more than half the total time spent with the patient on the date of service is allowed to bill for the service. For 2023 and recommended for 2022, we would recommend the QHP documenting the most substantive portion of medical decision-making or documented as having spent the most time dedicated to the visit should be the billing QHP.

The secretary of the US Department of Health and Human Services (HHS) signed an extension to the COVID-19 public health emergency (PHE) allowing for continued use of telehealth and telephone visits regardless of patient location until October 13, 2022. By law, a PHE can only be enacted for 90 days; the PHE for COVID-19 originally enacted on January 31, 2020, has been renewed each 90 days as it approached expiration. The HHS secretary has indicated his intention to provide 60-day notice before allowing the PHE to expire. Most expect the PHE to be extended again in October.

Updated Medicare Economic Index (MEI) for calendar year 2023: 

CMS is proposing to rebase and revise the MEI cost share weights for calendar year 2023 and is soliciting comment. The MEI measures the input price pressures of providing physician services. CMS is proposing a new methodology for estimating base year expenses that relies on publicly available data from the US Census Bureau’s North American Industry Classification System code 6211 Offices of Physicians to allow for the use of data that are “more reflective of current market conditions of physician ownership practices, rather than only reflecting costs for self-employed physicians, and will allow for the MEI to be updated on a more regular basis.” Using the new MEI cost weights to set MPFS rates would not change overall spending on MPFS services but would likely result in significant changes to payments among MPFS services. In consideration of its ongoing efforts to update to MPFS payment rates with more predictability and transparency, and in the interest in ensuring payment stability, CMS is proposing not to use the proposed updated MEI cost share weights to set MPFS payment rates for calendar year 2023. However, CMS is soliciting comments on the potential use of the proposed updated MEI cost share weights to calibrate payment rates and update the Geographic Practice Cost Index under the MPFS in the future.

Requiring manufacturers of certain single-dose container or single-use package drugs to provide refunds with respect to discarded amounts: 

Section 90004 of the Infrastructure Investment and Jobs Act amended section 1847A of the act, adding provisions that require manufacturers to provide a refund to CMS for certain discarded amounts from a refundable single-dose container or single-use-package drug. The refund amount is the amount of discarded drug that exceeds an applicable percentage, which is required to be at least 10% of total allowed charges for the drug in a given calendar quarter. The proposals to implement section 90004 of the act include how discarded amounts of drugs are determined, a definition of which drugs are subject to refunds (and exclusions), when and how often CMS will notify manufacturers of refunds, when and how often payment of refunds from manufacturers to CMS is required, refund calculation methodology (including applicable percentages), a dispute resolution process, and enforcement provisions. Although this proposal does change reimbursement protocols for physicians or change reporting requirements for physicians, if adopted as proposed, it may affect some pharmaceutical companies and the packaging of certain drugs.

. Published online July 29, 2022. https://bit.ly/3p0ZlAf

Conversion factor for 2023 is set to decrease by approximately 4.4%.

What’s in the Medicare Physician Fee Schedule proposed rule?

My provider performed urodynamics for a man with benign prostatic hyperplasia (BPH) and performed a complex cystogram using calibrated electronic equipment with a pressure flow test. My provider pulled CPT codes 51728 and 51741. I didn’t see a separate uroflow test documented to bill CPT code 51741, but my provider advised me that the uroflow was recorded during the pressure flow part of the examination, so their coding was correct. Who is correct?

There are a number of urodynamic tests that can be performed. Urodynamic studies are not a one-size-fits-all procedure, but rather the tests performed should be chosen based upon the patient presentation and the question that needs to be answered by the urodynamic studies. Only the medically necessary tests should be billed, and only the tests that need to be performed should be performed. In this particular case, the patient had BPH-type symptoms and therefore the question that needs to be answered is whether the patient’s voiding symptoms were due to obstruction or not. This is best answered using a pressure-flow test. Therefore, the best test to perform is CPT code 51728 (Complex cystometrogram; with voiding pressure studies[ie, bladder voiding pressure)], any technique). (In addition, the add-on CPT code +51797 [Voiding pressure studies, intra-abdominal] [ie, rectal, gastric, intraperitoneal], which is an add-on code to bill with 51728 or 51729, can be billed if performed.)

The other diagnostic test that is often used for men with BPH symptoms is CPT 51741 (Complex uroflowmetry [eg, calibrated electronic equipment]). Uroflowmetry measures the urine flow electronically, with the flow rate reflecting the combined activity of the detrusor muscle, bladder neck, and urethral function. A limitation of uroflometry is that a decreased flow rate is not specific for obstruction or poor bladder functioning. The only way of truly differentiating obstruction from poor detrusor contraction is by a pressure flow test. If a uroflow test had previously been performed on the patient, there would be no medical necessity to perform the test again. If a pressure-flow test is being performed, there would need to be justification of medical necessity to perform a concomitant uroflow test. A pressure-flow test (CPT 51728) is a separate test from uroflowmetry, so uroflowmetry should only be billed if performed separately on separate equipment.There are those who mistakenly believe that CPT 51741 is part of the pressure-flow tests so is always billed in addition to CPT 51728 even if there is no separate uroflow test; that is not correct. Based upon the documentation of the case listed above, we agree with you that CPT 51728 should be reported and CPT 51741 should not. Even if CPT 51741 was performed separately, we would want to see justification of medical necessity.

"There are a number of urodynamic tests that can be performed. Urodynamic studies are not a one-size-fits-all procedure, but rather the tests performed should be chosen based upon the patient presentation and the question that needs to be answered by the urodynamic studies," write Jonathan Rubenstein, MD, and Mark Painter.

Urology Coding: Can CPT 51728 and 51741 be billed together?

I am having issues billing an unlisted code for a new procedure the doctor is performing. Do you have any suggestions for appropriate billing of an unlisted code?

Unlisted codes are not unfamiliar to urology practices. According to Current Procedural Terminology (CPT) coding instructions, when procedures or services performed by physicians do not have a valid or descriptive CPT or Healthcare Common Procedure Coding System (HCPCS) code, the service should be reported using an unlisted code. The unlisted code selected must be from the appropriate anatomic section of codes.

Any procedure or service billed with an unlisted code must be appropriately documented in the medical record. The medical record should include an accurate description of the service provided, the associated results (as applicable), and clear and discernable medical necessity for the service. Clinical documentation must be submitted for reimbursement for virtually all unlisted codes. Payer review of the medical documentation will first determine whether the unlisted code is appropriate for the service provided. If there are no other applicable codes available, the payer will next review the medical record for medical necessity and appropriateness of the service.

Appropriateness of the service for new services will include analysis of safety (FDA approval, if appropriate) and efficacy of the service. You may be required to provide supplemental information that supports the safety and efficacy of the service in the form of peer-reviewed documents for some unlisted services.

Because there is no set description for these miscellaneous or unlisted procedure codes, you will need to enter a description of the service or procedure provided. Most practice management systems will provide an appropriate field to enter the description for the service provided. If you are billing the same service for more than 1 patient encounter, it is important to provide a consistent description with the unlisted procedure code.

You may also enter additional supporting information for the service, such as comparative service code(s) or code(s) that have a CPT definition and assigned reimbursement to help the payer determine both the effort and equipment required and to help determine reimbursement. Again, most practice management systems will have a field for entering this type of information. The field information, when printed on a Centers for Medicare & Medicaid Services (CMS) claim form, will display in Box 19. Note that printed documents and field length in an electronic claim are limited; be judicious in your wording. We have noted that some systems will combine fields from the description and additional information fields on the printed CMS form. As most are now billing electronically, you may not see the final format in the electronic form.

If you are entering information in all the required fields and you are still having problems with the payer processing the claim at the point of submission, you may wish to review with your practice management system vendor what limitations the system presents and how the information is parsed on the electronic claim. You may also need to speak with your payer regarding special requirements for that payer.

As mentioned previously, documentation of the service is often required prior to payment. Although some payers will allow submission of clinical documentation prior to initial payment review, the attachment of clinical documents to a claim is dependent on your system, clearinghouse abilities, and the payer. It may require some trial and error to determine when and how documentation can be provided to support the services provided.

Coverage of unlisted codes is a separate issue. As some unlisted codes are used to report techniques, new devices used, or new services, the payer may or may not consider the service as experimental or not covered. You should always check with your payer to determine whether the service will be covered, if possible. We understand this process is oftentimes consuming and, in many cases, will result in noncommittal or even a lack of true direction. The contact of the payer prior to provision of the service is wise.

Although these types of services require additional work, the limitations of the CPT system and the speed of code development require that a good billing department understand how to submit and follow unlisted services for adequate payment. This may also require appeal of payment amount and submission of additional supporting data such as invoices or comparative time and work estimates—be prepared and tenacious.

Supplemental information on safety and efficacy of service may be needed.

Jonathan Rubenstein, MD

Articles

Is seminal vesiculectomy included within the prostatectomy code?

What’s in the Medicare Physician Fee Schedule proposed rule?

Urology Coding: Can CPT 51728 and 51741 be billed together?

What to know about billing for unlisted codes