Physician's call is deciding factor in cancer code

March 1, 2007

Codes vary by cancer type, but liability for bladder Ca diagnosis rests with the doctor

A. Billing a diagnosis of cancer for a patient who has at one time been diagnosed with cancer is a point of debate in many specialties. Each cancer is viewed differently, and specialty organization consensus among providers is currently the single best source of information for appropriate cancer diagnosis use.

Q. I am new to urology coding, and wondered if one could bill for a penile block when performing a meatotomy. I am also unsure about which nerve the penile block falls under. The urologist gave the penile block for postoperative pain control. 64430 is used for a pudendal block, and 64450 is for a peripheral nerve; I thought the latter would be correct. When I run codes 53020 and 64450 through the CCI edits, a modifier –59 can be appended to 64450 to bypass the edit, but I was unsure if this was appropriate to control post-op pain. Please give your opinion as to which code should be used and whether modifier –59 would be appropriate.

A. Unfortunately, you should no longer charge for the penile block while performing a meatotomy. CPT includes the local infiltration in the surgical package. Medicare has gone one step further and bundled the injection code into the procedure.

You are correct about the nerve block. The correct code is for the injection of the anesthetic into the nerve is 64450.

64450 is included (bundled) in 53020. The CCI edits state that it can be removed from the bundle and billed separately by appending the –59 modifier to 64450. Unfortunately, it would be inappropriate to add the modifier –59, because the injection is being performed in conjunction with the meatotomy and is not an unrelated or "distinct" procedure. You cannot use a modifier unless the circumstances surrounding the services meet the definition of the modifier. Just because the edits say you can does not mean you should.

Control of post-op pain is usually considered follow-up care similar to wound care, removal of sutures, and other related services. However, many offices are billing and being paid for pain control services under the auspices of care above and beyond what is normal. Although you may be successful in payment for these services, the cost and effort for providing these services is minimal and should be included.

Q. Please educate me about ICD-10, which I hear we will be required to use. What is it, and when are we going to have to use it?

A. ICD-10 actually has two separate parts: diagnosis and procedures. Currently, there are no plans to adopt the procedural part of ICD-10. If adopted, it would take the place of CPT, and there is a lot of support for continuing CPT.