Mark Painter is CEO of PRS Urology SC in Denver.

Mark Painter

Our doctor is called to consult on a patient in urinary retention. The hospital nursing staff is unable to pass the Foley catheter. During the consult, the doctor places the Foley catheter. The physician bills for the hospital-visit evaluation and management and CPT 51702, but I think I’m thinking too much because the lay terms of 51702 state the physician supplies the Foley… so it’s still OK for my provider to report the E/M and 51702, and the hospital will bill for the supplies only. Is this correct? Or is there a modifier that can be added to the 51702 in order for the doctor to bill for the placement?  

	With our complicated billing system, it is easy to “think too much.” Before we get to the meat of your question, we should issue a warning: Don’t let the “lay terms” sidetrack your thinking. “Lay” descriptions are helpful to many in understanding what a service or procedure may entail, but these descriptions are not a part of CPT or any other official rule set. In short, consider them as additional information, but do not use this information to guide or change your coding.

	For your questions, we “think” it would help to reword your question and then answer with more than a simple yes or no.

	First, is it OK to bill for 51702 in the hospital setting?

	When you’re paid for the procedure in the office, you are paid a higher fee than when you perform the same procedure at the hospital. Look up 51702 in AUACodingToday, scroll down to “fee schedule,” and look at “facility fee.” The national payment is $27. The non-facility fee, or office fee, is $65.88. This additional payment is for the catheter and the office expenses. In short, it is not only OK to report 51702 in the hospital, it is in fact the correct way to report the simple insertion of a Foley catheter in the hospital.

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	Second, do you need a modifier to report 51702 in the hospital?

	No, the correct place of service is all you need to communicate to the payer that the hospital is charging a “facility fee” in addition to your charge for the procedure.

	We assume that you do know you will need a modifier –25 attached to the E/M code to report the consultation (E/M code) on the same date as the catheter insertion.

Next: Question regarding bladder instillations

A press release from Imprimis Pharmaceuticals, Inc. includes the following: “According to the [AUA], bladder instillations are considered a second line treatment option when self-management treatments do not provide symptoms relief. Hep-Lido-A's new user-friendly kit includes a hydrophilic catheter, and ready to use sterile pre-filled syringes, providing added convenience for in-office instillation as well as for patients who perform at-home instillations.” I have two questions about this. First: Are there different coding requirements for in-office procedure versus home? Second: Can you bill separately for the kits? If you can, what codes do you bill? 

	Code 51700 (Bladder irrigation, simple, lavage and/or instillation) is the correct code to use when a physician or employee of the physician instills a drug like Hep-Lido-A in the office setting. Payment for services in the office include typical supplies like gloves, exam table paper, local anesthesia if used, syringes, catheters, etc. Drugs (other than drugs used for local anesthesia) are typically allowed as a separate charge, unless they are considered to be self-administered drugs (SADs). SADs are defined typically as drugs administered by the patient over 50% of the time.

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	Unfortunately, the administration of Hep-Lido-A for interstitial cystitis does not match typical administration for heparin sodium or lidocaine HCL assigned to the J codes for these drugs. Therefore, reporting of Hep-Lido-A will require J3490 (Unclassified drugs) with a description of the drug in box 19 and most likely an invoice proving that you paid for the drugs as well as the amount. Payment for the drug “kit” under J3490 should be checked with the payer prior to administration.

	SADs are not covered under Medicare Part B. Therefore, you cannot bill for kits provided to the patient for self-administration using CPT codes to your Medicare carrier.

	Even though SADs are not covered by Medicare Part B, the kits may be eligible for coverage under Part D Medicare. If you are considering dispensing kits for home use, you will need to look into obtaining a pharmacy license. Requirements for these licenses vary by state and payment for SADs will vary by payer. Many offices have obtained the correct licensing to dispense SADs to patients.

When can modifier –25 be used with an E/M code?

	Exploring in-office pharmacy and the benefits to the practice and your patients will require a careful study of your facility, your demographics, and your staff. We recommend development of a full business plan prior to executing the work required for licensing.

Next: Question regarding penile modeling during IPP placement

Is it true that penile modeling during inflatable penile prosthesis placement for penile curvature is included in the prosthesis insertion bundle (CPT 54405), or can it be billed separately with CPT 54360?

	The description for code 54405 (Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir) is straightforward for the insertion of the IPP, with no mention of modeling or angulation correction.

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	According to the National Comprehensive Coding Initiative edits (as checked on AUACodingToday), 54360 (Plastic operation on penis to correct angulation) is not considered to be bundled with code 54405. These services would suggest that both codes may be reported to Medicare and private payers.

	However, the global definition of a procedure in CPT and in payment protocols for Medicare and most private payers dictates that services commonly required to complete a procedure should not be reported separately. Therefore, you should consider the efforts required on each patient in whom you implant an IPP. If the services provided are atypical due to clinical presentation and require significant extra effort to correct the angulation above and beyond the standard IPP insertion, reporting of both services should be allowed.

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	Send coding and reimbursement questions to Ray Painter, 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.

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In this "Coding Q&A" column, Ray Painter, MD, and Mark Painter also answer questions regarding bladder instillations and penile modeling during IPP placement.

How to bill for catheter placement in the hospital setting

Coders, billers, and physicians are much more knowledgeable now than when we started working with practices over 25 years ago. There has also been a steady increase in automation throughout the billing, documentation, and coding process. Despite the increase in knowledge and increased use of automation, we continue to see many costly billing, documentation, and coding mistakes. 

In this article, we will review mistakes made throughout these processes and what you can do to prevent them.

Access Project, a health care advocacy group, has determined that 80% of all medical bills contained mistakes, according to an Aug. 2, 2017 

“Easy tips for physicians to reduce billing errors.”

 Kaiser Health reported that $68 billion is lost to health care spending because of medical billing mistakes.

Billing rules and payer requirements have become more and more detailed and restrictive. The margins within which physician practices operate continue to decrease. Electronic medical records, practice management systems, and other automated tools used by practices require too much time and manual effort to use correctly. New quality and value programs are requiring more time and effort with little visible benefit to patient care or outcomes.

The health care field is in many ways no different than the broader market. As the system becomes more complex, practices have to continue to innovate, educate, and improve internal systems to keep up with both the clinical and administrative demands of the system. Like it or not, human interface is a key component. Input into the system must be accurate, and the outcome of the automated processes must be monitored to ensure that the information is correct. “Garbage-in/garbage-out” is applicable to today’s medical billing process.

In our work with practices around the country, we see mistakes being made in every step of the complicated and detailed process. Collecting patient data, identifying the services provided, accurate service documentation, determining the correct codes, submitting the claim, and accurate follow-through are a few of the common failure points in the process.

Today’s billing process requires a team effort in every practice. Many of you are familiar with what we’ve called the “Wheel of Fortune” detailing the 18 to 20 steps that are required to accurately code, bill, and collect.

Here are just a few examples of areas and actions that we see as common points of failure during the billing process.

 Incorrect demographic data, inaccurate insurance/coverage information, prior authorization. Solution:

Attention to detail by practice staff, including collecting all required information, scanning documents, and entering data correctly and in the correct fields.

Leverage all available tools: Understand your practice management system, upgrade when required, conduct routine training, find external tools and plug-ins to address deficiencies, analyze performance, and provide feedback to your team.

Collect before or at the time of service any co-payments, co-insurance, and past due balances. Setting proper expectations is half the battle. Communicate with your patients and provide accurate and complete information.

Be patient and be diligent, but move forward.

 Failure to report all services provided, incomplete documentation, inadequate communication from provider to billing department, and inaccurate coding, including the wrong level of evaluation and management service provided. Solution:

Proper and consistent communication, including feedback among clinical and administration, is required.

Double checks in the protocol are a must. Do not rely solely on your EMR code (E/M) calculator. Review coding-both manual and automated-regularly, with a focus on accuracy. Both upcoding and downcoding should be addressed through training.

Understanding of service coding is beneficial for both data input accuracy and output accuracy. Lead by example; a physician who does not care about coding accuracy may be perceived as not caring about billing accuracy. Your staff will follow your lead. Online video and in-person seminars targeted to physicians are available from the AUA, Physician Reimbursement Services Network, and other sources; use them all.

Continuous training of billing staff and clinical staff, including quick reference material, such as the “Pocket Card” and auacodingtoday.com, are invaluable. Use multiple sources and assess both learned and retained information.

 Improper modifier use. Two specific examples follow.

 Modifier –25 is both overused and underused due to a lack of understanding of how it should be used. Solution:

Updated, accurate, practice-wide policies and training to promote consistent application and understanding of proper use are essential for both data input (chart documentation) and output (coding and billing).

Understand payer-specific requirements for use of this modifier relative to diagnosis and service combinations.

 Modifier –59 and the “X” modifiers. The problem here is overuse and misuse. Solution:

Practice-wide policies and training to promote consistent documentation for services that may require use of modifier –59 or –X (E, S, P, U) modifiers should be implemented.

Billing staff, including certified professional coders, will need to continue educational updates and obtain practical experience with payers for each practice.

Consistent communication pathways among clinical and administrative staff should be developed to include messaging and meetings with specific, targeted agendas.

 Automated posting is not an excuse to allow payers to process claims without review. Solution:

Analyze non-paid claims and payment level for each service.

Correct and resubmit mistakes made by office for payment.

Medicare has made it clear when denying a claim that the agency is sending a message and does not expect practices to keep making the same mistake. When claims are denied, they should be appealed to demonstrate the mistake was Medicare’s or billing staff should communicate office errors to prevent future errors and then either reprocess with corrections or appeal with documentation.

Do not fall behind. Lack of claims follow-up is a compounding error and timely follow-up is well worth the effort. Attention to detail, even on small claims, adds up quickly. PRS  contracts to work accounts receivable projects for multiple practices around the country with excessive A/Rs due to lack of time, staff, and/or neglect. Many of the unpaid or underpaid claims can be systematically identified, repaired, resubmitted, and collected.

In summary, physicians, as leaders of the team, need to be more knowledgeable and more involved, and pay attention to the details. In addition, they need to demand excellence in education and performance by their entire team. Conducting periodic checkups is required. Being too busy taking care of patients and ignoring the business you run can be very costly.

Physicians are very trusting and hire people that they know have the expertise to do the job. They don’t question their expertise or the jobs they’re doing. This is a good thing in many ways. However, to quote W.C. Fields: “Trust everyone, but cut the cards.” Each employee must be held accountable for their actions. The office needs to know that everyone who touches the many steps in the revenue cycle has the knowledge, expertise, and understanding of the tools and expectations to do their job. In addition, staff members should be encouraged to update and continue their education.

We encourage you to look at your data entry, documentation, billing, and collections in depth throughout the year. Whether you own the business or are employed, are “hands on” or are detached from the billing process, you are ultimately responsible for bills submitted in your name. The battle to end billing mistakes will require continued analysis, diligence, and leadership.

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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.

In this article, we review mistakes made throughout the billing, documentation, and coding processes and what you can do to prevent them.

 An earlier version of this article contained an error. In a question and answer discussing vasectomy coding, the statement, “Code 55450 remains an active CPT code and can be used to report a sterilization procedure in which the vas deferens is ligated with a suture and no portion of the cord is removed or cut,” was incorrect. Code 55450 has been deleted. Code 55250 (Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination[s]) is the correct code to use. The corrected response can be read 

A patient has a large bladder stone (~3.5 cm), part of which is trapped in a bladder diverticulum. How should I bill robotic cystolithotomy along with robotic diverticulectomy?

There are no specific codes for either the laparoscopic (robotic) diverticulectomy nor cystolithotomy. From a pure coding perspective, the proper code would thus be 51999 (Unlisted laparoscopy procedure, bladder). When submitting an unlisted code for a procedure, you of course need to submit your documentation and we recommend a cover letter or explanation of the service including a comparative value or charge based on a similar code. Your staff is likely aware that you may be able to attach supporting documentation electronically at the time you submit the claim through your practice management system or clearinghouse to save some time.

If we explore codes outside of the laparoscopic (robotic) code series, CPT does have codes 51050 (Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection) and 51525 (Cystotomy; for excision of bladder diverticulum, single or multiple [separate procedure]). According to the National Correct Coding Initiative, you should code only 51050, as code 51525 is included in 51050. Note that unbundling is never allowed. This type of bundling edit is common with codes designated as “(separate procedures).”

When reporting the unlisted code, we would recommend including a value-based comparison to code 51050 that may also include a documented increase in work effort due to the size of the stone and inclusion of the diverticulectomy, if appropriate (ie, the procedure took 150% of the time for a standard cystolithotomy due to large size of the stone and difficulty of extracting the stone from the diverticulum including repair of the bladder).

As an alternative, some payers may be willing to accept the 51050-22. The description of procedure code 51050 does not specify the procedure as open in the description.

However, the approach of using the traditionally “open” procedure code for a laparoscopic (robotic) procedure is not widely accepted, thus our initial recommendation for code 51999. The method of coding for laparoscopic codes using traditional “open approach” codes has been endorsed by some payers and is mentioned as an option for coding by AUA representatives for the laparoscopic (robotic) cystectomy.

As is common with these difficult coding conundrums, we encourage you to check with the payer prior to reporting in this way.

Next: Coding a percutaneous tumor resection

I am an endourologist at the University of Michigan with a question regarding coding of percutaneous tumor resection of a large upper tract urothelial cancer. For these cases, I perform a cystoscopy and retrograde pyelogram (52005, 74420) to assist my colleague with getting percutaneous access (50395). I then perform a resection of the tumor percutaneously. This is quite an involved surgery that is more similar to a percutaneous nephrolithotomy than anything else. My coders tell me that despite the complexity of the surgery (sometimes it takes 3 hours), we are supposed to use the renal endoscopy with biopsy code (50555, work relative value unit 6.5) rather than nephroscopy through nephrotomy codes (50574, etc.). The difference in RVU is tremendous. What are your thoughts on how to code a percutaneous tumor resection? I would expect it to be closer to a PCNL.

Your list of codes (descriptions listed in table below) for establishing the access-52005, 74420-26-and your colleague’s (assuming he/she is from a different specialty/practice) coding of 50395 are accurate.

We are puzzled by your coders’ recommendation to use code 50555 (Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy), when code 50562 (Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with resection of tumor) appears to be more descriptive of the procedure, assuming that you are using renal endoscopy to resect the tumor as the overall question implies.

Code 50562 does carry a 90-day global as opposed to code 50555, most likely due to the longer follow-up required for a treatment as opposed to a diagnostic biopsy. As you can see from the table, code 50562 has a work RVU closer to the PCNL code 50080.

In summary, you would bill Medicare 50562, 52005 (if billing to a private payer, add modifier –51), and 74420-26, and your colleague would bill 50395.

If you are performing the resection without the use of renal endoscopy, your coders may be referencing a different code set for which there is no resection of tumor code.

For vasectomy coding, when is it appropriate to use 55450 instead of 55250? My coder is telling me that 55450 is an outdated code that should no longer be used.

Code 55450 (ligation [percutaneous] of vas deferens, unilateral or bilateral [separate procedure]) has finally been deleted, removing the confusion for all. Vasectomies are reported with code 55250 (vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]).
	 

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

"When submitting an unlisted code for a procedure, you of course need to submit your documentation and we recommend a cover letter or explanation of the service including a comparative value or charge based on a similar code," write Ray Painter, MD, and Mark Painter.

I have a patient that had an extracorporeal shock wave lithotripsy (90-day global), and the physician saw the patient within the 90 days to counsel the patient on how to prevent future stones. The physician wants to bill an evaluation and management. Can this be done? 

	This is a great question and one we have discussed frequently over the years. The answer is maybe.

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	As we have discussed the issue among ourselves and with others, we have been forced to conclude at this point that you should not charge for stone prevention during the global period of a service provided to treat stones 

However, for those patients who truly have an underlying condition diagnosed by the physician that will more than likely cause additional stones and will require more medical management and provider effort than the average stone patient, you should consider reporting the visit.

	To arrive at a more detailed and targeted answer, you have to ask yourself several questions. Was the discussion of a routine nature that is needed with most stone patients? What was the medical necessity for having that discussion with this patient? Was the discussion related to stone prevention, or was it for the treatment of a disease process? Was there significant, extra work performed over and above the routine follow-up for the surgery?

NEXT: Looking at the definition of modifier –24

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	First, we looked at the definition of the only modifier that will allow billing for E&M services during a global period, modifier –24: “Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.”

The argument that the prevention of stones is unrelated to the reason for the procedure is one that we have formulated and discussed several times. The argument goes something like this: “Clearly, the stone burden removal with ESWL is directed at existing stones, which are considered to be treated during the procedure, and the related care will include monitoring the success of the procedure as well as treatment for recovery. As the counseling for a patient is intended to ‘treat’ future stones through prevention, it appears the definition of modifier –24 would allow for reporting the E&M service provided.”

	One of the problems in the end is the potential for nonpayment by a payer. If a payer considers the overall treatment of the stones as the   problem for which the ESWL was provided, then the discussion of prevention could be considered a part of the global care of the patient. Is it common procedure for a physician to discuss prevention of a problem as a routine in the care of a patient? Is it good medicine to simply treat the stone burden and not advise the patient of ways to prevent this problem in the future? It is hard to argue that good patient care would not include this discussion. Many payers have latched on to this, and therefore consider care that is provided to a patient relating to stones as not unrelated and therefore should be included in the global.

	The other definition we have considered is the Medicare definition of global period and, specifically, what is not included in the surgical package. According to the Medicare Claims Processing Manual (Chapter 12-Physicians/Nonphysician Practitioners Section 40.1.B Services Not Included in the Global Surgical Package), the following visits are considered payable within a global period:

		visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur 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.

	There are other items in the list, but these are the most relevant to this discussion. The first point, indicating visits that are unrelated to diagnosis for which the surgical procedure is performed, is hard to get around. It is hard to declare that the treatment is for a condition unrelated to the reason for the surgery. The stone likely was present due to the patient’s metabolism and underlying condition.

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	Regarding the second point, it would appear that the visit would be allowed for those cases that go above and beyond the normal care provided to the majority of patients in the recovery period.

	From a processing standpoint, if the diagnoses are the same or considered to be related within Medicare’s database, the claim will be denied and an appeal will be required. Based on the list of services not included in the Medicare-defined global, it would appear that one would need to satisfy only one of the bullet points listed. Therefore, documentation must support that the condition is underlying and indeed an added course of treatment that is clearly not a part of the normal recovery from surgery is necessary. Even with these arguments met, the fact that the visit is related to the reason for the surgery may result in a second denial of the service.

	The final issue we have considered is a discussion regarding treatment versus prevention. Medically necessary and reasonable treatment is covered by Medicare if other rules are considered. Prevention, on the other hand, is only covered under specific circumstances. This fact may also prevent coverage, as payers may not consider the fact that you are treating the underlying diagnosis and consider any lifestyle changes recommended as preventive services and therefore not covered, even in a situation where the patient is outside the global.

In summary, if this is a routine discussion following a stone removal in which you are recommending increased fluid intake, some dietary changes, etc., then perhaps, for reasons stated above, such as minimal extra work, routine good patient care etc., there should not be an additional charge for this type of service provided in the global regardless of payer.

	However, if this patient has a problem such as abnormal lab work, the diagnosis of underlying causes for recurrent stones, etc., requiring significant, medically necessary additional work, then this service could be legitimately charged. Documentation should clearly identify the reason for the visit and the treatments prescribed and, for Medicare at least, you must be prepared for an appeal and perhaps an uphill battle for final payment.

	The bottom line, for the submitted question, is that we would need to see the documentation for that visit before we would say “yes” or “no” as to our recommendations in charging for this service, as the circumstances will dictate the answer.

NEXT: OK to bill two instillation codes for one appointment?

We would like to know if it is OK to bill two instillation codes (51700) for one appointment. The scenario is that medications are being placed within the urethra to treat conditions of the urethra, and subsequent to that, medications via catheter are being placed within the bladder to treat a condition within the bladder. I have asked a couple of sources to weigh in on this. One brought up that the urethral treatment might be considered anesthesia prior to the bladder treatment, in which case it would be included. Another source said, “I would bill the 51700 only once as this CPT code has a medically unlikely edit (MUE) of 1, indicating this code can only be billed once per encounter. The clinical scenario does not indicate that modifier 

59, one of the new X modifiers, or other modifier would be correct in obtaining payment for a second 51700.”

Could you please provide us with your opinion? I have included a sample chart note of this procedure:

“Heparin Instillation: Patient was prepped using DMSO, sodium bicarbonate, and lidocaine gel at the urethral meatus and suprapubic heat prior to the procedure. Betadine prep was performed followed by insertion of an 8F pediatric catheter without incident. The following medications were mixed and instilled: heparin 40,000 unit injection solution; bupivacaine (PF) 0.5% (5 mg/mL) injection solution; lidocaine (PF) 20 mg/mL (2%) intravenous solution; sodium bicarbonate 1 mEq/mL (8.4%) intravenous solution. The catheter was then removed.”

Continue to the next page for the answer.

	Based on the information you have provided in the note above, we would recommend charging 51700 only once. Our reasoning is as follows:

		It appears from the note that the solution for the urethra is in fact used as a preparation for the procedure. “Patient was prepped using DMSO, sodium bicarbonate, and lidocaine gel at the urethral meatus and suprapubic 

 (emphasis added). This would indicate that the treatment is provided to prepare the patient for treatment. Based on the medications used and the lack of any clear diagnosis or reason for treatment of the urethra other than to prepare for the insertion of the heparin, the service appears to be that of a local anesthetic. As local anesthesia is included per CPT global guidelines, the service is included in the instillation of the heparin and should not be reported, regardless of payer.

		The definition of code 51700 in CPT is “Bladder irrigation, simple, lavage and/or instillation.” The code by definition does not include a mention of urethral instillation; reporting this code for the urethral portion of service described is not appropriate. Unfortunately, the urethral instillation does not have a code in CPT at this time. Based on this, we would not recommend reporting 51700 to any payer for the urethral portion of the service.

		The MUE for code 51700 is in fact 1. This edit is specific to Medicare and those payers that have adopted this rule for payment. While this issue is clearly payer specific, it is also fairly commonly used with larger payers. MUEs are problematic to work around without a clear medically necessary reason and manual review. The note you have included as mentioned above does not support exceeding the MUE for this code.

	Your further comments with regard to the –X [E, S, P, U] and –59 modifiers are correct based on the definition of global listed in the first bulleted item in relation to the documentation that you have provided.

	Send coding and reimbursement questions to Ray Painter, 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.

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In this Coding Q&A column, the Painters discuss the tricky question of whether you can bill for stone prevention counseling, and also answer a question about whether you can bill two instillation codes (51700) for one appointment.

Mark Painter

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How to bill for catheter placement in the hospital setting

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Is billing for stone prevention counseling possible?