Q. Is there a diagnosis code for penile fracture and a specific code for repair of the fracture?
A. Use ICD-10-CM diagnosis S39.840A Fracture of corpus cavernosum penis. ICD-10 and new CPT code 54437 Repair of traumatic corporeal tear(s).
Q. How do I code for a patient's condition when I have not determined a diagnosis?
A. When you see a patient and cannot immediately determine a final diagnosis without lab results or other pending information, code the visit with ICD-10 coding, indicating the signs and/or symptoms that prompted ordering the test. Do not bill with an unconfirmed, possible diagnosis. Once the test results have been determined, then bill any subsequent visits with the confirmed ICD-10 diagnosis code. If the diagnostic test results are normal, use ICD-10 codes for the signs and/or symptoms that prompted the treating physician to order the study.
Q. When do I stop using the cancer ICD-10 codes and begin using the personal history Z codes on a patient I treated for cancer?
A. You should use the cancer diagnosis as long as the patient is under active treatment. At the end of the treatment, if there are no signs and symptoms of the cancer, you may begin using the Z codes. But there are exceptions. If the patient is taking cancer-suppressing drugs, continue to use the cancer ICD-10 codes, as the cancer is only under control and is not gone. The assignment of the diagnosis of cancer is under the judgment of the physician.
AUA Coding & Reimbursement Committee agreed that AUA members should follow the official coding guidelines listed in ICD-10-CM, which are:
- When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.
- When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.
- There is no specific timeframe associated with coding this disease only what is specified in the guidelines.
The following therefore is a quick summary on how to choose the correct ICD-10 code for cancer patients:
- If the patient is under active management of the disease (medical/surgical, for example chemotherapy, hormone therapy, radiation therapy, planning surgical therapy, etc.) or has active disease, use the appropriate specific cancer code.
- If the patient is under active surveillance of the disease (for example, after treatment with curative intent, even if surgery recently performed), use the "personal history" or specific Z85 code.
- Follow the insurers' instructions.
Q. Can I bill for a urinalysis and bladder scan during the postoperative period?
A. During the postoperative period, any type of laboratory/pathology or radiological procedure should be reimbursed by the insurance carrier. For Medicare, the reason that these types of services are allowed is because they have an "XXX" global which states that "the global concept does not apply to this code." Therefore they are not bundled into the global period of a surgery. There has been a problem with CPT® code 51798 Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging, in the last year because it was moved to the Urinary System Section of CPT®. Some carriers are mistaking this for a surgical procedure when it is clearly a radiological procedure and carries the "XXX" global. It may be necessary to appeal these types of claims with your insurance carrier.
Q. Our urologist dictates the office notes and gives them to our transcriptionist. At the end of the notes, the transcriptionist types "Dictated but not read." The doctor does not review or sign the dictation. Will this pass an audit?
A. No. As any audit is based on documented notes in a patient's chart, the physician is responsible for the accuracy of his dictated material. The urologist must read and sign all documents in the patient's chart not only for medical and auditing reasons, but also for legal reasons.
Q. Our patient saw his urologist and internist on the same day – two entirely different physicians in two different practices. The claim for the urologist was denied. Can we appeal this decision?
A. Yes, this is definitely a case where an appeal should be pursued. Submit a cover letter with your appeal and outline the reason for the visit, medical necessity, and ask that this claim be reconsidered.
Q. What is the diagnosis code for Peyronie's disease?
A. ICD-10-CM diagnosis code, N48.6, was established for Peyronie's disease.
Q. Can I bill Medicare for a 99211 "nurse" visit with the chemotherapy administration code?
A. No. The lowest level E/M service 99211 will not be reimbursed with the chemotherapy administration code.
Q. Will a -25 modifier still be required when an E&M Service (99212-99215 or 99202-99205) is provided on the same day with chemotherapy administration?
A. As of January 1, 2004, if an evaluation and management (E&M) service is provided by the physician or other Medicare approved healthcare provider (PA/NP) on the same day as the chemotherapy injection, then the E&M service must have the -25 modifier, Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service modifier appended to it. Make sure your documentation describes the medical necessity of the E&M service provided.
Q. Does the AUA have any documentation to assist with denied claims for certain urologic procedures?
A. The AUA has developed several clinical appeal letters to assist offices in appealing their denied claims. They are available on AUAnet.
Q. My office is located within a Health Professional Shortage Area (HPSA) and/or a Physician Scarcity Area (PSA). Is a modifier necessary to get the quarterly bonus?
A. Depending on certain criteria, a modifier may be required to receive the HPSA/PSA quarterly bonus.If you furnish services to Medicare beneficiaries in a geographic HPSA that is not on the list of ZIP codes eligible for automatic payment, you must use the AQ modifier, "Physician providing a service in an unlisted Health Professional Shortage Area (HPSA)," on the claim to receive the bonus payment. Services submitted with the AQ modifier are subject to validation by Medicare. You must ensure that you use the modifier only for services provided to a Medicare beneficiary in an area designated as a geographic primary care HPSA (or a mental health geographic HPSA for psychiatrists) as of December 31 of the prior year. More information is available at CMS.gov.
Q. How do I code for Physician Quality Reporting System (PQRS)?
A. The Physician Quality Reporting System (PQRS) sunset in 2016. However, the new Quality program (part of the Merit-based Incentive Payment System) is very similar. The AUA has designed various tools to help its members participate in this program.
Q. What is the proper CPT code for no scalpel vasectomy?
A. The proper CPT code for no scalpel vasectomy is 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s).
Q. When submitting a claim for Testopel do I use the unclassified drug code?
A. For Testopel we recommend using J3490 unclassified drug. This would need to be submitted on a paper claim, we have provided an example [pdf].
Q. Can you explain the proper documentation for urodynamic, we are having a hard time having physician document for urodynamic?
A. When documenting for urodynamic you need supporting documentation to be able to support all the CPT codes that are being billed. We have an example of proper documentation you may want to share with your physicians. View the full Urodynamics Coding and Documentation Requirements [pdf]
Q. Can we start administering Xiaflex in our office can you verify the proper coding?
A. Xiaflex is carrier discretion, so we recommend you verify benefits before administering the medication. There are a total of three visits for the patient to return to the office. We have a list of the codes for every visit you need to submit.
Q. I am trying to locate information on billing CPT 55876 Gold Seed Placement and the A4648 Implantable Tissue Markers – I am unable to locate Medicare reimbursement information for A4648. Can you provide further information?
A. HCPCS A4648 does not have a set reimbursement, it is carrier discretion. A copy of the invoice must be sent with the claim. If the urologist purchased the seeds you would then submit the claim with CPT code 55876 Gold seed markers and CPT code 76942 if there is supporting documentation.