It is always recommended that, in addition to the clinical circumstances that caused the increased work, you include a relative time reference to justify the additional fee.
Q What is the CPT code for cystoscopic urethral realignment with Foley placement post-motorcycle accident?
One additional charge that may apply would be E&M services. If you clearly document history review, physical examination (likely limited), and medical decision making, an E&M with modifier –25 may be warranted.
Q What are the most appropriate codes to use when coding for a cystectomy/prostatectomy with urinary diversion?
Select the cystectomy code with the appropriate diversion and lymphadenectomy as listed in the description included in the documentation. In addition, bill the appropriate prostatectomy code. Of note in each of the present coding combinations, with the exception of 51596, the appropriate code is 55840 for the prostatectomy, as the lymph node removal is included in the description of the correct cystectomy code for each technique under most circumstances. Thus, only a cystectomy with continent diversion would be reported with the prostatectomy with nodes (55845). If the description does not adequately describe the lymph nodes removed, you will need to bill the appropriate lymphadenectomy codes and then bill the cystectomy and prostatectomy codes without lymphadenectomy.
Also, none of the code combinations above are bundled under the Correct Coding Initiative; therefore, if you were to add a modifier, you would add modifier –51 to the prostatectomy code, and the lymphadenectomy codes, if they are billed separately.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRSUrology SC in Denver.