Coding Companion for Urology/Nephrology a Comprehensive Illustrated Guide to Coding and Reimbursement

Coding Companion for Urology/Nephrology A comprehensive illustrated guide to coding and reimbursement

2015 Contents

Getting Started with Coding Companion ...... i Scrotum ...... 328 Integumentary...... 1 Vas Deferens...... 333 Arteries and Veins ...... 15 Spermatic Cord ...... 338 Lymph Nodes ...... 30 Seminal Vesicles...... 342 Abdomen ...... 37 Prostate ...... 345 Kidney ...... 59 Reproductive ...... 359 Ureter ...... 116 Intersex Surgery ...... 360 Bladder...... 153 Vagina ...... 361 Urethra ...... 226 Medicine ...... 371 Penis...... 266 Appendix...... 385 Testis ...... 303 Evaluation and Management ...... 411 Epididymis ...... 318 Index...... 433 Tunica Vaginalis ...... 325

CPT © 2013 American Medical Association. All Rights Reserved. © 2014 OptumInsight, Inc. Coding Companion for Urology/Nephrology Contents appropriate endoscopic procedure code 590.2 Renal and perinephric abscess — (Use 50576-50580 (50570–50580) and 50045 or 50120. For additional code to identify organism, 50576 Renal endoscopy through nephrotomy or open renal endoscopy (through nephrotomy such as E. coli, 041.41-041.49) or pyelotomy), with examination only, see pyelotomy, with or without irrigation, 592.0 Calculus of kidney 50570; ureteral catheterization, with or instillation, or ureteropyelography, without dilation of the ureter, see 50572; 592.1 Calculus of ureter exclusive of radiologic service; with biopsy, see 50574. Percutaneous renal 593.4 Other ureteric obstruction fulguration and/or incision, with or without endoscopic procedures (through established 593.81 Vascular disorders of kidney biopsy nephrostomy/pyelostomy) are reported with 599.60 50580 with removal of foreign body or 50551–50562. Urinary obstruction, unspecified — calculus (Use additional code to identify ICD-9-CM Procedural urinary incontinence: 625.6, 788.30-788.39) 55.01 Nephrotomy 599.70 Hematuria, unspecified 55.03 Percutaneous nephrostomy without fragmentation 599.71 Gross hematuria 55.11 Pyelotomy 599.72 Microscopic hematuria 55.21 Nephroscopy 753.3 Other specified congenital anomalies of kidney 55.22 Pyeloscopy 788.0 Renal colic 55.23 Closed (percutaneous) (needle) biopsy of kidney 958.5 Traumatic anuria 55.39 Other local destruction or excision of Terms To Know renal lesion or tissue biopsy. Tissue or fluid removed for diagnostic Anesthesia purposes through analysis of the cells in the 00860 biopsy material. ICD-9-CM Diagnostic foreign body. Any object or substance found in an organ and tissue that does not 189.0 Malignant neoplasm of kidney, except belong under normal circumstances. pelvis Kidney 189.1 Malignant neoplasm of renal pelvis CCI Version 18.3 198.0 Secondary malignant neoplasm of 0213T, 0216T, 0228T, 0230T, 12001-12007, kidney 12011-12057, 13100-13153, 36000, 36400-36410, 36420-36430, 36440, 36600, 199.2 Explanation Malignant neoplasm associated with 36640, 37202, 43752, 50392, 50395, transplanted organ — (Code first The physician examines the kidney and ureter 50562-50570, 50684, 51701-51703, complication of transplanted organ with an endoscope passed through an incision 62310-62319, 64400-64435, 64445-64450, (996.80-996.89) Use additional code in the kidney (nephrotomy) or renal pelvis 64479, 64483, 64490, 64493, 64505-64530, (pyelotomy). After accessing the renal and for specific malignancy) 69990, 76000-76001, 77001-77002, ureteric structures with an incision in the skin 209.24 Malignant carcinoid tumor of the 93000-93010, 93040-93042, 93318, 94002, of the flank, the physician incises the kidney kidney — (Code first any associated 94200, 94250, 94680-94690, 94770, or renal pelvis and guides the endoscope multiple endocrine neoplasia 95812-95816, 95819, 95822, 95829, 95955, 96360, 96365, 96372, 96374-96376, through the incision. To better view renal and syndrome: 258.01-258.03; Use 99148-99149, 99150 ureteric structures, the physician may flush additional code to identify associated Also not with 50576: 50555, 50574, 50955, (irrigate) or introduce by drops (instillate) a endocrine syndrome, as: carcinoid saline solution. The physician may introduce 50974 syndrome: 259.2) contrast medium for radiologic study of the Note: These CCI edits are used for Medicare. renal pelvis and ureter (ureteropyelogram). In 209.64 Benign carcinoid tumor of the kidney Other payers may reimburse on codes listed 50576, the physician passes through the — (Code first any associated multiple above. endoscope an instrument that destroys lesions endocrine neoplasia syndrome: by electric current or incision The physician 258.01-258.03; Use additional code Medicare Edits may insert an instrument to biopsy renal to identify associated endocrine Fac Non-Fac tissue. In 50580, the physician passes syndrome, as: carcinoid syndrome: RVU RVU FUD Status instruments through the endoscope to remove 259.2) 50576 16.34 16.34 A0 a foreign body or calculus, and may pass a 223.0 Benign neoplasm of kidney, except 50580 17.62 17.62 A0 stent through the ureter into the bladder. The physician sutures the incision, inserts a drain pelvis MUE Modifiers tube, and performs a layered closure. 223.1 Benign neoplasm of renal pelvis 50576 80*N/A50511 233.9 Carcinoma in situ of other and 50580 80*N/A50511 Coding Tips unspecified urinary organs * with documentation Medicare References: None If the nephrotomy or pyelotomy is done for 236.91 Neoplasm of uncertain behavior of an additional, significantly identifiable kidney and ureter endoscopic service, report both the

© 2014 OptumInsight, Inc. CPT © 2013 American Medical Association. All Rights Reserved. 112 — Kidney Coding Companion for Urology/Nephrology Explanation with contrast; and 74178 if performed first without 74000 Computed tomography directs multiple thin beams contrast in one or both body regions followed by the injection of contrast and further sections in one 74000 Radiologic examination, abdomen; single of x-rays at the body structure being studied and or both body regions. anteroposterior view uses computer imaging to produce thin cross-sectional views of various layers (or slices) of Explanation the body. It is useful for the evaluation of trauma, 74190 tumor, and foreign bodies as CT is able to visualize 74190 Peritoneogram (eg, after injection of air or Films are taken of the abdominal cavity in one view soft tissue as well as bones. Patients are required to contrast), radiological supervision and from front to back. Because an abdominal x-ray remain motionless during the study and sedation interpretation usually precedes another diagnostic imaging may need to be administered as well as a contrast procedure, it is not coded separately unless medium for image enhancement. These codes Explanation performed as a separately identifiable examination. report an exam of the abdomen. Report 74150 if no contrast is used. Report 74160 if performed with A radiographic exam is done on the peritoneal cavity 74010 contrast and 74170 if performed first without to define the pattern of air in the cavity after 74010 Radiologic examination, abdomen; contrast and again following the injection of injection of air or contrast. The physician inserts a needle or catheter in to the peritoneal cavity and anteroposterior and additional oblique and contrast. injects air or contrast as a diagnostic procedure. cone views X-rays are then taken. The needle or catheter is 74174 removed. This code reports the radiological Explanation 74174 Computed tomographic angiography, supervision and interpretation for a peritoneogram. Films are taken of the abdominal cavity from front abdomen and pelvis, with contrast Use a separately reportable code for the procedure. Appendix to back, with an oblique view and a focused (coned material(s), including noncontrast images, down or spot) view. Because an abdominal x-ray if performed, and image postprocessing 74400 usually precedes another diagnostic imaging 74400 Urography (pyelography), intravenous, procedure, it is not coded separately unless Explanation with or without KUB, with or without performed as a separately identifiable examination. Computed tomographic angiography (CTA) of the abdomen and pelvis is performed with contrast tomography 74020 material and image postprocessing. CTA is a procedure used for the imaging of vessels. CTA of Explanation 74020 Radiologic examination, abdomen; the abdomen and pelvis may detect aneurysms, Radiographic imaging of the kidneys and ureters is complete, including decubitus and/or erect thrombosis, and ischemia in the arteries supplying done before and after the administration of an views blood to the digestive system, as well as locate intravenous contrast material to identify gastrointestinal bleeding. Contrast medium is rapidly abnormalities of the kidneys and urinary tract. Explanation infused at intervals, usually with an automatic Abdominal films are first obtained and then the Films are taken of the abdominal cavity from front injector, and the patient is scanned with thin section contrast medium is injected into a vein. Radiographs to back, back to front, or front to back with the axial or spiral mode x-ray beams. The images are again obtained while the contrast material is patient lying on the side and/or standing. Because obtained are acquired with narrower collimation being excreted. This is also known as intravenous an abdominal x-ray usually precedes another and reconstructed at shorter intervals than standard pyelography or IVP. This procedure may be done diagnostic imaging procedure, it is not coded CT images. Three-dimensional images are generated with or without KUB, a general abdominal x-ray, or separately unless performed as a separately and postprocessing reconstruction is done at a with or without tomography, x-rays taken onto film identifiable examination. workstation on the scanner. Noncontrast images, moving opposite the beams to yield a single plane if performed, are also included in this procedure. shadowless image. 74022 74022 Radiologic examination, abdomen; 74176-74178 74410-74415 complete acute abdomen series, including 74176 Computed tomography, abdomen and 74410 Urography, infusion, drip technique and/or supine, erect, and/or decubitus views, pelvis; without contrast material bolus technique; single view chest 74177 with contrast material(s) 74415 with nephrotomography 74178 without contrast material in 1 or both Explanation body regions, followed by contrast Explanation material(s) and further sections in 1 or Radiographic imaging of the kidneys and ureters is Films are taken of the abdominal cavity with the done immediately following an infused intravenous patient lying flat, standing, and/or lying on the side. both body regions drip or a rapid bolus injection of contrast agent. A This procedure includes an upright chest x-ray. front to back film of the abdomen is taken after Because an abdominal x-ray usually precedes Explanation contrast administration. Report 74415 if done with another diagnostic imaging procedure, it is not Computed tomography directs multiple thin beams nephrotomography, x-rays taken onto film moving coded separately unless performed as a separately of x-rays at the body structure being studied and opposite the beams to yield a single plane identifiable examination. uses computer imaging to produce thin, cross-sectional views of various layers (or slices) of shadowless image. This can be used to check the the body. It is useful for the evaluation of trauma, patency of a nephrostomy tube. 74150-74170 tumor, and foreign bodies as CT is able to visualize 74150 Computed tomography, abdomen; soft tissue as well as bones. Patients are required to 74420 without contrast material remain motionless during the study and sedation 74420 Urography, retrograde, with or without 74160 with contrast material(s) may need to be administered, as well as a contrast KUB 74170 without contrast material, followed by medium for image enhancement. These codes contrast material(s) and further sections report an exam of the abdomen and pelvis. Report 74176 if no contrast is used; 74177 if performed

This section provides an overview of evaluation and management guidelines. The qualified health care professional may report services (E/M) services, tables that identify the documentation elements independently or under incident-to guidelines. The professionals associated with each code, and the federal documentation within this definition are separate from “clinical staff" and are able to guidelines with emphasis on the 1997 exam guidelines. This set of practice independently. CPT defines clinical staff as “a person who guidelines represent the most complete discussion of the elements works under the supervision of a physician or other qualified health of the currently accepted versions. The 1997 version identifies both care professional and who is allowed, by law, regulation, and facility general multi-system physical examinations and single-system policy to perform or assist in the performance of a specified examinations, but providers may also use the original 1995 version professional service, but who does not individually report that of the E/M guidelines; both are currently supported by the Centers professional service.” Keep in mind that there may be other policies for Medicare and Medicaid Services (CMS) for audit purposes. or guidance that can affect who may report a specific service.

Although some of the most commonly used codes by physicians of all specialties, the E/M service codes are among the least Types of E/M Services understood. These codes, introduced in the 1992 CPT® manual, When approaching E/M, the first choice that a provider must make were designed to increase accuracy and consistency of use in the is what type of code to use. The following tables outline the E/M reporting of levels of non-procedural encounters. This was codes for different levels of care for: accomplished by defining the E/M codes based on the degree that certain common elements are addressed or performed and reflected • Office or other outpatient services—new patient in the medical documentation. • Office or other outpatient services—established patient The Office of the Inspector General (OIG) Work Plan for physicians • Hospital observation services—initial care, subsequent, and consistently lists these codes as an area of continued investigative discharge review. This is primarily because Medicare payments for these • Hospital inpatient services—initial care, subsequent, and services total approximately $32 billion per year and are responsible discharge for close to half of Medicare payments for physician services. • Observation or inpatient care (including admission and discharge services) The levels of E/M services define the wide variations in skill, effort, and time and are required for preventing and/or diagnosing and • Consultations—office or other outpatient treating illness or injury, and promoting optimal health. These codes • Consultations—inpatient are intended to represent physician work, and because much of this work involves the amount of training, experience, expertise, and The specifics of the code components that determine code selection knowledge that a provider may bring to bear on a given patient are listed in the table and discussed in the next section. Before a presentation, the true indications of the level of this work may be level of service is decided upon, the correct type of service is difficult to recognize without some explanation. identified.

At first glance, selecting an E/M code may appear to be difficult, but Office or other outpatient services are E/M services provided in the the system of coding clinical visits may be mastered once the physician or other qualified health care provider’s office, the requirements for code selection are learned and used. outpatient area, or other ambulatory facility. Until the patient is admitted to a health care facility, he/she is considered to be an Providers outpatient. The AMA advises coders that while a particular service or procedure A new patient is a patient who has not received any face-to-face may be assigned to a specific section, the service or procedure itself professional services from the physician or other qualified health is not limited to use only by that specialty group (see paragraphs 2 care provider within the past three years. An established patient is a and 3 under “Instructions for Use of the CPT Codebook” on page x patient who has received face-to-face professional services from the of the CPT Book). Additionally, the procedures and services listed physician or other qualified health care provider within the past throughout the book are for use by any qualified physician or other three years. In the case of group practices, if a physician or other qualified health care professional or entity (e.g., hospitals, qualified health care provider of the exact same specialty or laboratories, or home health agencies). subspecialty has seen the patient within three years, the patient is considered established. The use of the phrase “physician or other qualified health care professional” (OQHCP) was adopted to identify a health care If a physician or other qualified health care provider is on call or provider other than a physician. This type of provider is further covering for another physician or other qualified health care described in CPT as an individual “qualified by education, training, provider, the patient’s encounter is classified as it would have been licensure/regulation (when applicable), and facility privileging by the physician or other qualified health care provider who is not (when applicable)” State licensure guidelines determine the scope available. Thus, a locum tenens physician or other qualified health of practice and a qualified health care professional must practice care provider who sees a patient on behalf of the patient’s attending within these guidelines, even if more restrictive than the CPT physician or other qualified health care provider may not bill a new