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Medicare recently made it clear that you should be able to charge for procedures performed on two separate lesions, which are not contiguous, in the same organ.
Q: I recently operated on a patient with two separate stones located in separate parts of the same kidney. I was able to remove both through the ureteroscope, using laser. Can I charge for both? If so, how?
A: Yes, you can charge for both and should be paid for both. Medicare recently changed the rules to limit the use of the –59 modifier. In the process, Medicare clarified the definition of modifier –59 as it relates to a separate or distinct procedures. Medicare made it clear that you should be able to charge for procedures performed on two separate lesions, which are not contiguous, in the same organ. Medicare has stated that modifier –59 is “Only appropriate if procedures are performed for lesions anatomically separate from one another or if procedures are performed at separate patient encounters.”
Since the stones were located in two separate parts of the kidney, they should fit the definition of “two separate lesions.” Reporting should include the following codes and modifiers:
The –76 may be unnecessary, but we recommend using it to emphasize the second charge was not a duplicate charge. The placement of a stent, if provided, would be billed without a modifier or with modifier –51, as it is not bundled into code 52353.
Q: I am working with a critical access facility that is having issues with billing for bladder instillations. I noticed your previous article on this subject (“Know when to charge for bladder instillation,” November 2011, page 38) and was hoping you could answer my question. Per CPT 2012 surgery coding, the supplies and medications are included in a procedure unless they are above and beyond the supplies normally used. Are the drugs normally used in bladder instillations included in the procedure, or can they be billed separately?
A: As noted in the previous article, there are different types of bladder instillations:
Make sure that you are coding correctly for the instillation based on the type of drug you are using. In the office setting, charge separately for the drugs that are instilled using the appropriate J codes. Charging for other supplies used is not allowed.
In a facility setting of any type, the physician is not paid for supplies or drugs. In fact, the payment rate in a facility is lower to the physician provider to account for this non-payment. The facility bills separately in either the inpatient or outpatient setting. We assume that your question is directed primarily as a concern for outpatient payment. Under the Outpayment Prospective Payment System (OPPS), certain drugs and biologicals can be paid separately from the procedure in certain circumstances. The drug/solution utilized in the instillation will need to be checked for status under the OPPS payment database.
In the case of bladder instillations, it appears that bacillus Calmette–Guérin (TheraCys, TICE BCG) is paid separately, for example. A listing of all payable instillation solutions is not possible in this article, and we would encourage any further questions to be directed to Physician Reimbursement Systems at email@example.com.
With the critical access facility, the differences can be significant for both the amount paid and the way the claim is paid. As this is varied based on the election of the provider instilling into the bladder and the critical access facility, each facility will have differing coding and reimbursement issues. That being said, the general answer to your question is the critical access facility will be able to report the drug separately for many instillations but not the supplies.
Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at UT@advanstar.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.