Multiple stones: Watch for –59 modifier replacements


In this "Coding Q&A" column, Ray Painter, MD, and Mark Painter answer several reader questions involving billing for multiple stones, including replacements for the –59 modifier, use of CPT code 50590, and NCCI guidelines and multiple stones.

Since we have the new code 52356, would you suggest that we bill for multiple stones in one kidney as follows: 

• 52356

• 52353

• 52353-59-76?

For private, non-Medicare, payers, if you had three totally separate, non-contiguous stones that were treated with lithotripsy and then a stent was inserted, the above coding would be correct. However, for Medicare, the answer has changed. (Note that the answers to the second and third questions relate to this topic as well.)

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We have been asked many times, “How could you talk about the same topic year after year after year?” Our answer is always simple: “You don’t even have to change the questions, because the answers keep changing.” Unfortunately, the answer to questions about modifier –59 and multiple stones has changed multiple times during the past few years. The current answer is that, for Medicare, you cannot charge separately for the treatment of multiple stones on the same side of the urinary tract.

“Same side” includes stones in the kidney, renal pelvis, or ureter regardless of mode of treatment. If the patient’s insurance is Medicare, Medicaid, or another federally funded program that uses Medicare rules, you should report only one treatment per side.

The AUA received a letter several months ago from the director of the National Correct Coding Initiative (NCCI) indicating that it would be incorrect to use the –59 modifier to report separate treatments for any additional stone on the same side. We think he is absolutely incorrect in making this ruling. The AUA Coding and Reimbursement Committee agrees that it was incorrect and is appealing the decision.

Apparently, CMS also agrees that the ruling was incorrect, or at least the agency understands the problem. CMS issued a transmittal indicating four new modifiers will replace/supplement modifier –59 in January 2015. Stay tuned for suggestions on the correct uses of those modifiers in later publications. In short, the answer to this question will change again in January.


Next: Question regarding CPT code 50590 (extracorporeal shock wave lithotripsy)

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I have a question regarding CPT code 50590 (extracorporeal shock wave lithotripsy). All of my coding materials show that 50590 can only be billed one time per side, whether the urologist treated more than one stone in the kidney or kidney and ureter. Can you clarify this?

As explained above, for Medicare patients, you cannot charge for more than one stone on the same side at the same setting, regardless of how it is treated.

ESWL presents a special problem in treating non-Medicare patients. The majority of ESWL cases are performed on single stones; therefore, reimbursement for the code is based on the work effort required to position and treat a single stone. So if a physician is treating a second stone, which requires a significant amount of additional time and effort, there should be a way to report an additional treatment with the appropriate modifier. How to report this remains up in the air.

CPT code 50590 includes no clear guidance on number of stones or number of treatments rendered. Some have interpreted the code to mean that ESWL is one charge, regardless of the number of stones or positions required. Others have interpreted the description to mean that each separately positioned ESWL should be coded separately.

An additional consideration should be given to the technical component. If an additional “shock plug” has to be used, then there should be a way to allow the facility to recoup the extra costs associated with the service.

Based on the interpretation that the code is all-encompassing for a single encounter, the best way to report the extra effort required for repositioning and treatment of separate stones would be to append modifier –22 to code 50590. Recall that this method of reporting will likely require supporting documentation and manual review.

Based on the interpretation that the code is in fact descriptive of a single positioning and treatment, reporting multiple ESWL positions for the treatment of multiple stones would allow for reporting 50590 for each new position/new stone during a treatment session. The current modifiers available to report more than one procedure are –51 (will not unbundle) and –59. Given current bundling and payment rules, –59 would likely be the appropriate modifier.

Either approach may require appeal and should be checked against any agreed-upon contract policy for the payer. Remember, Medicare has already offered an interpretation blocking reporting of multiple treatments on the same side.


Next: NCCI guidelines and multiple stones


We follow the NCCI guidelines that state the following relating to multiple stones:

“Some lesions of the genitourinary tract occur at mucocutaneous borders. The CPT Manual contains integumentary system (CPT codes 10000-19999) and genitourinary system (CPT codes 50000-59899) codes to describe various procedures such as biopsy, excision, or destruction. A single code from one of these two sections of the CPT Manual that best describes the biopsy, excision, destruction, or other procedure performed on one or multiple similar lesions at a mucocutaneous border should be reported. Separate codes from the integumentary system and genitourinary system sections of the CPT Manual may only be reported if separate procedures are performed on completely separate lesions on the skin and genitourinary tract. Modifier 59 should be utilized to indicate that the procedures are on separate lesions. The medical record should accurately describe the precise locations of the lesions.”

Can you provide any clarification regarding this passage in NCCI and the correct coding for the treatment of multiple stones?

The guidelines you have quoted specifically address lesions and are guidelines included in the NCCI manual. NCCI guidelines are developed under contract from Medicare to provide payment guidance to Medicare payers. It appears from your question that you have chosen to follow these guidelines for payers other than Medicare or payers specifically stating they will follow Medicare guidelines. We will answer your question as it applies to Medicare, but want to clarify that your application of the directive from Medicare to other payers is not required.

The guideline appears to focus on mucocutaneous lesions that may affect both the genitourinary tract and the integumentary system. Interpreting this strictly on the NCCI guideline quoted above, it would appear that NCCI is directing that treatment of a lesion that extends from the genitourinary tract out into the skin should be reported with a single code, either from the genitourinary section or the integumentary system of CPT.

Rather than the strict interpretation of the guideline listed, we are going to assume that the lesion reference is based on previous articles we have written regarding multiple stones. The reference to NCCI guidelines in our previous articles was specifically related to their interpretation of the use of modifier –59. Rather than rewrite those articles, we will summarize the position taken in them.

Our position was that stones are similar to lesions in that they can occur in the same organ system; they require separate work to treat if in fact multiple stones were diagnosed prior to the surgery and may require not only separate work effort but may also require separate techniques and clearly separate effort. If separately identified lesions are allowed to be paid separately, separate stones should be treated similarly and therefore could be called lesions.

This position created a bit of controversy, and as such, a request for clarification was sent to Medicare from the AUA. Medicare responded in a letter to the AUA specifically stating that stones are not lesions and therefore the guideline above cannot be applied to stones. Further, Medicare has stated that treatments of multiple stones are not allowed to be charged separately regardless of treatment method for the same side, as noted in the first question above. As also stated in the first question, the AUA has officially disagreed with this interpretation (not as it relates to the portion of the letter stating that stones are not lesions but to the fact that treating of multiple stones should not be separately reported) and it appears that Medicare may be listening; we will keep you posted.

In short, the NCCI guideline quoted above does not appear to apply to multiple stones.UT  

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