Mark Painter is CEO of PRS Urology SC in Denver.

Mark Painter

I was reading an article regarding different approaches to remove a previously placed ureteral stent and ran into a coding dilemma. One of our providers was performing a percutaneous nephrolithotomy for a large kidney stone on a patient with a previously placed ureter stent. The provider grasped the upper end of the stent with a grasper placed through the percutaneous nephroscope and removed the stent through the percutaneous sheath. Our provider insists on billing Current Procedural Terminology (CPT) code 52310 in addition to the percutaneous nephrolithotomy, but I am unsure. Can you clear this up for us?

You are correct in questioning the use of CPT code 52310 for this approach to remove a previously placed ureter stent. CPT code 52310 (cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple)describes removal of a ureteral stent from the urethra or bladder using a cystoscope to directly visualize and grasp the stent, foreign body, or calculus. This is not the approach described in your question above, which states that the provider removed the stent directly from the kidney from the percutaneous approach. Therefore, coding CPT 52310 in this situation would not be correct. CPT 52310 could be coded if the stent was removed by inserting a cystoscope into the bladder for stent removal, if not bundled to another service.

Based on this discussion, one may also be tempted to bill CPT code 50561 (renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus) or CPT code 50580 (renal endoscopy through nephrotomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus) which, when used alone, would more accurately describe the removal of a stent percutaneously through a nephrostomy or nephrotomy using a nephroscope.

However, before electing to report either of these 2 codes, it is important to check the National Correct Coding Initiative (NCCI) bundling edits for the other services that were provided during the surgical session. For example, CPT code 50080 (percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm) and CPT code 50081 (percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm)both include CPT code 50561, so they cannot be coded together if the procedures are being performed on the same renal unit. Modifier 50 or XU would be required if these codes were to be reported on the contralateral renal unit.

One additional consideration that will need to be considered for the procedures performed is the specific policy established for retrograde stent exchange, which only allows reporting insertion of a stent if a stent is removed during the same operative session as the insertion.

Although no such policy is included to address an antegrade stent exchange, the physician documentation should clearly support the separate effort required to remove the existing stent, as required for the use of modifier 59 or XS.

1. NCCI Policy Manual [1/1/21] Chapter VII surgery: urinary, male genital, female genital, maternity care, and delivery systems CPT CODES 50000-59999 for National Correct Coding Initiative policy manual for Medicare services, Paragraph c:19

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.

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Check for surgical approach and bundling edits when choosing a code.

Urology Coding: Removal of previously placed ureter stent presents dilemma

In July 2021, the Centers for Medicare & Medicaid Services (CMS) released its proposed rules for the Medicare Physician Fee Schedule (MPFS) and for the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center (OPPS/ASC) Payment System. We had discussed this and our thoughts on these proposed rules in our August 2021 column.

 Societies and interested parties were able to provide their thoughts on the proposed rules to CMS during the comment period. The biggest impacts on urology involved the proposed reduction in the conversion factor (CF) and the effect of updated clinical labor rates on nonfacility-based procedures. On November 2, 2021, CMS released its final rules for the MPFS and OPPS/ASC Payment System outlining the policies to be implemented on January 1, 2022. Despite comments from interested parties hoping for changes, CMS adopted much of what had been proposed in July.

The CF for 2022 is scheduled to be $33.5983, a decrease of 3.71% from the current $34.8931. This decrease is primarily due to the expiration of a 1-time contribution from the trust fund as directed by one part of the of the Consolidated Appropriations Act of December 2020, which raised the CF by 3.75% for the 2021 calendar year only. This reduction will directly affect payment for work performed by providers for patients covered by Medicare and Medicare Advantage plans. The relative value unit (RVU) changes overall are projected as a 0.0% impact based on the full volume of services for the specialty code payments. Taken in combination, this means that urology as a specialty will see a 3.71% decrease in overall payments in 2022 despite providing the same volume of services. The impact will not be equal for all urologists based upon their practice patterns and case mix.

As noted in our August 2021 article, clinical labor rates had not been updated in nearly 2 decades but were proposed to be updated for 2022. The concern was that these rates would dramatically increase due to being nearly 2 decades behind and, when plugged into a budget-neutral system, would lead to significant shifts in the reimbursement for practice expenses. The net effect of a significant shift would benefit services with high clinical labor rates but would adversely affect the reimbursement for services with low clinical labor yet high expenses, such as nonfacility-based surgical procedures, especially those with high device or nonlabor practice expense.

Because of this, there was a push by many to have CMS delay the implementation of this change for at least 1 year while the true effects could be further studied, and/or to implement a device offset for the device-intensive procedures. Unfortunately, neither of these asks were accepted by CMS in the final rule. However, the final rule did allow a 4-year phase-in of the updated clinical labor rates, which would let practices adjust to this change. In addition, CMS will use the median Bureau of Labor Statistics (BLS) wage data instead of the mean wage data, and the 2021 BLS fringe benefits multiplier of 1.296 as opposed to the 2002 BLS fringe benefits multiplier of 1.366. These changes will help mitigate the sudden and significant change to urology practices, at least in the short run. Practices will need to evaluate how this affects them both for 2022 and for years to come.

As noted above, the RVU changes for 2022 when adjusted for volume across all urologists are projected to be 0%. The global look at RVU changes does not tell the entire story and will not apply equally to all urologists. Only 11 codes with modifiers remained unchanged in total values for the Urology CPT section. Taking all RVU adjustments into account, most CPT codes in the Urology CPT section have slightly increased. The high volume of the negatively adjusted CPT codes offset the small increases for those positive RVU adjustments. Physician payments in the facility setting did not see many RVU changes.  No codes in the range increased by greater than 3.71%. CMany urology practices also must contend with decreases in fees associated with radiology and radiation oncology decreases due to RVU decreases on top of the CF decrease. For those groups with ambulatory surgical centers, the changes in code payment structure were limited and the overall payment was increased by approximately 2.0% for most services.

For the OPPS and ASC Payment System, CMS is increasing payment by a factor of 2.3%. Hospitals and ASCs that fail to meet their respective quality reporting program requirements are subject to a 2.0% reduction in the calendar year 2022 fee schedule increase factor, in continuation of existing policy.

For calendar year 2022, CMS will require clinicians to meet a higher performance threshold to be eligible for incentives following threshold requirements established for the Quality Payment Program’s Merit-based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorization Act of 2015. 2022 is the last performance year in which CMS will provide additional funds for exceptional performance; CMS will in future years only use penalties to fund bonus payments for exceptional performance. The threshold score for 2022 performance will be 75 with 30% of the score assigned to Quality and Cost categories, 25% to Promoting Interoperability, and 15% for Improvement Activities.

Split/shared visits are those where the service is provided in part by both the physician and non-physician practitioner (NPP) of the same group.While prior guidance was interpreted as limiting split/shared billing to established patients and not allowing critical care services to be split/shared, in 2022 CMS will change its policy and permit physicians and NPPs to bill for split/shared visits for both new and established patients and also for critical care services. Historically, the billing provider could be the physician if performing a “substantive portion” of the visit.CMS had proposed to allow billing by the practitioner who performed > 50% of the time of the service and would allow split/shared billing based upon time.In the Final Rule, there will be a 1-year transition period for this to take place, so during 2022 split/shared billing can be based upon time or medical decision-making using one of three key components of the visit (history, exam or medical decision-making) to qualify as the “substantive portion” of the visit. If performing a key component of the visit is utilized, the practitioner who bills the visit must perform and document the performance of that component in its entirety. For critical care services, which are time-based codes already, the physician or NPP must provide more than half of the total time in order to bill for the visit.

In the office setting, Shared/Split visits will not be allowed. CMS will continue to recognize “incident to” rules to determine how to classify services provided in the office setting. No changes were made to the “incident to” rules. We have seen many practices struggle with “incident to” billing for advanced practice providers (APPs). It is worth reviewing these guidelines and your practice’s policies every year. CMS also stated that Medicare will not recognize modifier -52 with E/M codes.

CMS is also finalizing the proposal to allow physician assistants (PAs) to directly participate in the Medicare program. Previously, a PA had to be contracted or employed by another qualified Medicare entity to bill Medicare. These changes in PA status are reflective of the growing contribution PAs make in the United States market regarding access to care and the increase in the team approach to health care. State licensure requirements must be met regarding supervision to qualify for participation in the Medicare program.

As we have stated previously, Medicare does not have the legislative power to open telehealth provided to patients outside of a Medicare-approved facility once the public health emergency (PHE) for COVID-19 expires. Although the current PHE is scheduled to expire January 15, 2022, based upon the time this article was written, this is reevaluated every 90 days, and it is possible or likely that this will be renewed again. In the final rule, Medicare included all codes from Categories 2 and 3 as covered services under telehealth rules until 2023 or the end of the calendar year in which the COVID-19 PHE expires, whichever is later (please refer again to our August 2021 article for further information).

After the PHE expires, CMS will no longer cover codes 99441-99443 (telephone only) visits but will revert to codes G2250-G2253 for virtual check-in visits and the codes for virtual management for nontelehealth remote visits. There are no proposed changes to rules for use of these codes. Once the PHE ends, you will need to review requirements for use of these codes if there is no legislative change to telehealth. CMS finalized the value for code G2252 at the same level as 99442.

CMS finalized its proposed rules for expanding coverage for remote treatment of patients based on a series of new codes to be added to CPT for remote therapeutic monitoring. These codes do not require the same number of days within a month that the patient remote monitoring codes require, filling a hole in the coding structure. Currently available remote monitoring codes require 16 days of monitoring within a month. The new remote therapeutic monitoring codes with few exceptions allow for medically appropriate number of days within the month for reporting purposes. The current focus of the codes appear to have limited application in urology, we will continue to review the codes and their appropriate use.CMS also indicated it will continue to engage in discussions with the American Medical Association and other concerned entities to expand access to care through remote services.

CMS created and maintained an Inpatient Only (IPO) list, which includes services Medicare will only pay for when performed in an inpatient setting because of their medical complexity. In the final rule for 2021, CMS decided to eliminate the IPO list over a 3-year period, with 298 services to be removed initially. However, CMS received numerous stakeholder comments opposing elimination of the IPO list mainly over patient safety issues. In the final rule for 2022, CMS halted the elimination of the IPO list and restored to the list the services removed in 2021, except for a few orthopedic codes. Procedures can still be removed from the IPO list if deemed appropriate based on Medicare criteria.

Changes to the ASC Covered Procedures List

Similar to the IPO list, in the 2021 final rule CMS added 267 surgical procedures to the ASC Covered Procedures List (CPL) beginning in 2021. However, CMS is restoring criteria for adding procedures to the ASC CPL that were there in calendar year 2020. Procedures can be added to the ASC CPL if they meet Medicare’s criteria. Three codes were proposed initially for removal and are being retained, including 2 urology CPT codes: 0499T (cystourethroscopy, with mechanical dilation and urethral therapeutic drug delivery for urethral stricture or stenosis, including fluoroscopy, when performed) and 54650 (orchiopexy, abdominal approach, for intra-abdominal testis [eg, Fowler-Stephens]). Also in the works is adoption of a nomination process, to begin in March 2022, to let external parties nominate surgical procedures to be added to the ASC CPL.

Appropriate Use Criteria program pushed back again

The somewhat controversial Appropriate Use Criteria program has been postponed again. Previously, the payment penalty phase of the program was to begin January 1, 2022. However, CMS now will not begin that phase until at least January 1, 2023, or the January 1 following the declared end of the PHE for COVID-19. This flexible effective date is intended to consider the impact that the PHE for COVID-19 has on practitioners, providers, and beneficiaries.

Based on the current path of Medicare and the MIPS/MACRA program revisions, it is hard not to feel déjà vu to the days of the sustainable growth rate when yearly patches were provided to maintain physician payment. Although there are efforts to avert the CF cut, we are hopeful but not convinced that Congress will take the action necessary to truly adjust the Medicare budgeting process to avoid the projected decreases in reimbursement as physician groups face increasing costs and administrative burdens. It will take the collective support of physicians and patients to initiate change to this now-outdated approach.

1. Rubenstein J, Painter M. 2022 CMS proposed rule represents another mixed bag for urologists. 

®. August 5, 2021. Accessed November 11, 2021. https://bit.ly/3ou4XT4

2. CY 2022 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1753FC). News release. Centers for Medicare & Medicaid Services. November 2, 2021. Accessed November 10, 2021. https://go.cms.gov/3qFupI2

Send coding and reimbursement questions to Rubenstein and Painter c/o

Urology as a specialty will see a 3.71% decrease in overall payments.

How the 2022 CMS final rule will affect urologists

Can you explain the difference and appropriate use of modifier -57 vs -25?

Although this may seem like a basic question for many coders, some do not fully understand the difference between these 2 modifiers. The definitions are as follows:

Modifier -25 describes a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.Modifier -25 should be appended to an E/M service when it is necessary to indicate that the patient’s condition required a significant, separately identifiable E/M service above and beyond the preop and postop services included in a CPT code that was performed on the same date. A significant, separately identifiable E/M service must be substantiated by documentation satisfying the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). Because the reported E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided, different diagnoses are not required for reporting both the E/M and procedural services on the same date. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery; in this case, modifier -57 would be used.

In contrast, modifier -57 describes decision for surgery. This should be appended to an E/M service that resulted in the initial decision to perform surgery.

In addition to the intended differences supported by CPT definition, the modifiers are treated differently by Medicare and other payers.

Modifier -25 is intended to indicate that an E/M service was provided, and documentation supports that the service was medically necessary, significant, and separate from the procedure reported on the same date. For payers, modifier -25 represents a frequently used and abused modifier in the CPT system. Payer bundling edits and rules have been adapted to allow the reporting of modifier -25 on the same date as services and procedures with any global period if the E/M service is considered bundled as part of the global period or through bundling edits when provided on the same date of service.

Modifier -57 is only used to report an E/M service during which the decision to treat the problem with surgery is made. In addition to the day of surgery, the modifier can be used prior to the day of surgery. Although a few payers still recognize modifier -57 when used to report same-day E/M services with minor procedures, defined by Medicare as a procedure with a 0-day or 10-day global, most payers now follow Medicare guidelines. Medicare limits the use of modifier -57 in published Medicare global guidelines to the day or the day before a procedure with a 90-day global.

Both modifiers are subject to review and are increasing associated with medical record requests. As always, document well and use the modifiers when appropriate.

"As always, document well and use the modifiers when appropriate," advise Jonathan Rubenstein, MD, and Mark Painter.

Urology Coding Q&A: Can you explain the difference and appropriate use of modifier -57 vs -25?

I have a coding question. Bilateral ureteral stent removal, CPT 52310. Can I bill 52310 2 units because it was performed bilaterally?

CPT 52310 has Medical Unlikely Edit (MUE)1, MUE Adjudication Indictor (MAI)3.

52310-76-GZ x for another unit, and expect the second procedure to be denied.

You have obviously done your research for this scenario. The short answer is that this will be paid once. The long answer requires understanding the terms you mentioned: MUE and MAI, which are used for payment policy for Medicare through the National Correct Coding Initiative. Any payer that follows Medicare guidelines will also likely follow these policies.

An MUE of 1 means the code will pay once per procedure. We had mentioned this situation before in a prior publication,1 and this MUE makes sense because the performance of CPT 52310 would include multiple passes into the bladder as needed if removing more than 1 foreign body.

For the MAI, if the indicator was a 1, that is an instruction to apply the MUE only to the claim line and would allow processing of multiple units of a code if the code is listed appropriately on separate claim lines. An MAI of 2 is an absolute date of service edit, meaning there are no circumstances under which a Medicare carrier or other payer following these rules will pay for more units than indicated by the MUE on a single date of service regardless of claim format or number of encounters. An MAI of 3, which includes CPT 52310, indicates that the MUE is considered a clinical benchmark date of service edit. This means all units for the date of service will be restricted to the MUE unit number unless there is a medically acceptable reason to deviate from the clinical benchmark.

Although one could argue whether the removal of bilateral stents is common enough to be considered a benchmark, the MUE rules go further to include reference to the Medicare Physician Fee Schedule Database (MPFSDB) rules. Unfortunately, of relevance to code 52310, the MPFSDB includes restriction of bilateral indicators for codes. Code 52310 has a “0” indicator for bilateral reference in the MPFSDB, meaning bilateral reporting is not allowed. Therefore, the MUE of 1 and MAI of 3 do not allow for reporting of more than 1 unit for a single session cysto with stent removal, and reporting the code regardless of modifiers used for the same session is incorrect coding.

If for a medically necessary reason 2 stents were removed on the same date at separate encounters, both may be paid after review and substantiation of the services for medical necessity.

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

"The short answer is that this will be paid once," according to Jonathan Rubenstein, MD, and Mark Painter.

Mark Painter

Articles

Urology Coding: Removal of previously placed ureter stent presents dilemma

How the 2022 CMS final rule will affect urologists

Urology Coding Q&A: Can you explain the difference and appropriate use of modifier -57 vs -25?

Can I bill 52310 2 units for bilateral ureteral stent removal?