SPEAKER_01 0:00

On this episode, ENM, coding a floor console with an OR decision. Also, bilateral pelvic lymphadnectomy denial. Finally, Same Incision Simple Prostatectomy with bladder stone removal. How do you code it? Stay tuned.

SPEAKER_02 0:20

Today's episode is brought to you by ModMed. Do your EHR and PM adapt to your style of practice? The ModMed EHR and PM do, with benefits like remembering preferences and automatically suggesting documentation and billing codes. Urologists voted ModMed the number one urology-specific EHR and PM solution available. Built by urologists with input from yours truly. Stop wasting 60 minutes and 200 for each of your open or no show slot. Go to modmed.com slash PRS Network, set up an appointment with the team at ModMed Urology, and shift your urology practice into high gear. Imagine a solution on a tablet or the web that works seamlessly with revenue cycle management, analytics, telehealth, payment processing, patient engagement tools, and much more. ModMed is transforming healthcare by placing doctors and patients at the center of care.

SPEAKER_01 1:21

Welcome to episode 298 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter, Dr. Ray Painter. And on today's episode, we want to cover a few questions. So let's dive right in. I'm going to read the question for you, Mark, and let's get see what you think. All right, first question. I am consulted to see a patient on the floor. They have a ureteral stone, and I make the decision to take them to the OR. Am I able to bill an initial encounter ENM code on the same day as a stone procedure or stent insertion? All right.

SPEAKER_02 2:01

What you got, Mark? Well, as usual, we're gonna start with the it depends. Because it always depends on exactly what the circumstance is. So I'm assuming, number one, that I'm consulted to see a patient on the floor, that you did go see a patient on the floor. You evaluated the patient, you actually looked through the patient's history, their imaging, and made the diagnosis of a stone and decided at that point in time that it was appropriate to take the patient to the OR. And you're taught in this question, you the answer, the question was stone procedure or a stent insertion. So we got a couple of choices, right, to do stone procedures. If the decision was to go for a PCNL to treat the stone, that's a 90-day global procedure. I think that's an easy one with the 57 modifier because the decision for surgery is not included in a major surgery or a surgery with a 90-day global from Medicare's guidelines. So that fits. And that may work for some private payers too, depending on how they work the definition there. Unfortunately, the insertion of a stent by or treatment of the stone with through a scope, those are all zero-day globals. And according to Medicare Globals, the visit immediately prior to surgery and prepping for surgery is included. So we have to go to what is not included, and that would be a significant or separately identifiable evaluation and management service. So the fact that you consulted the patient, and this is again where the depends come in comes in, and you were the one who actually made that final diagnosis of stone that needed to be treated that day, you could look at that as a significant and separate evaluation because the way the wording in the global is that if you're just working them up to go to surgery, that really wouldn't be a separately billable visit with your zero or 10-day global procedures. So that's where that note comes into play. I mean, was this something that you actually had to review the information because the patient had flank pain, they had a suspected stone, or they had a stone that could be managed in a bunch of different ways, there they weren't referred to you to basically perform a procedure through a ureteroscope or a cystoscope, in the case of the stent insertion, then you've got the argument for the modifier 25. And then, of course, with the PCNL on that side of the equation, you've got the decision for surgery. So you did make the decision for surgery there. So I think in both cases, the questions leading to say, I did make the decision for surgery. So I'm gonna assume that the answer is going to be yes, but that documentation, better support for the zero globes, that you did that separate medical decision making evaluation and everything else, but which included the decision for surgery rather than a quick workup to take them to surgery.

SPEAKER_01 6:00

Ray, thoughts, comments?

SPEAKER_00 6:03

Sounds good.

SPEAKER_01 6:05

All right, and that would be the so if you're in the hospital, that would be the 99222.

SPEAKER_02 6:10

Actually, we don't know. We don't know where they are. They're seen on the floor. So that could be an a standard office or other outpatient visit. It could be an emergency department visit, it could be an inpatient visit. It depends on what status the patient is, where they're located.

SPEAKER_01 6:31

Yeah. Yeah, I guess seen on the floor is a little broad.

SPEAKER_02 6:34

Yeah.

SPEAKER_01 6:35

Okay. That's fair. Okay, let's move on to the next one. The next question we had, and it actually came in during our webinar for EM and AI ambient listening scribes, or AI and or ambient listening scribes, which uh you can access if you want to listen to that discussion. It was a very interesting discussion that we had on at least Mark walked us through some of the things you just need to consider if you have the AI scribe and are using AI to do your documentation. But if you want to check that out, you can go to PRSnetwork.com and find the monthly webinar recordings. So they're available on PRSnetwork.com. Okay, so this question came in and it says my provider performed a laparoscopic prostatectomy with bilateral pelvic lymphadinectomy. And Humana denies the claim and states that we need to remove all three lymph nodes: the external iliac, the hypogastric, and the obturator. Mark, is that true?

SPEAKER_02 7:55

I tell you, this is one of those issues that has a lot of opinions and no true concrete answer, unfortunately. But I'm gonna lean on a couple of different things to say absolutely that is not true. And there are a couple of ways to appeal it, but without a definitive answer, that's gonna be one of those difficult things that we have to navigate, and we're talking about medical necessity and a few other things. So, first up, let's look at our options. We essentially have two codes that have robotic prostatectomies with lymph nodes now. Those are both new codes. We've got the 55868, which is the laparoscopic surgical prostatectomy retropubic radical, including nerve sparing, includes robotic assistance when performed, with limit with lymph node sampling. Then the parenthetical is limited lymphadinectomy. And then you have the 55869, which is laparoscopic surgical prosectomy, retroputic radic, retropubic radical, including nerve sparing, includes robotic assistance when performed, with bilateral pelvic lymphadonectomy, including and st external iliac, hypogastric, and obturator nodes. So I think that's where Cygna is hanging things on that including. Now, the definition of including we could explore in this single code. So one would be including nerve sparing. Which basically, if you didn't do the nerve sparing for the procedure, would it get denied for that? Probably not. That's extra work, and that's there. They clearly aren't going to allow you to bill for it separately under a different procedure, which we don't really have a code for anyway. But that's one of those areas, and then it includes robotic assistance when performed. So there's another use of the word includes or including with a modifier in verb or in verbiage when performed, indicating you could do this with or without a robot, and it doesn't change the code. So that one's a little bit clearer. Then we've got with bilateral pelvic lymphadenctomy. That essentially locks that in, that a bilateral pelvic lymphadenctomy needs to be done. The part then left is the including external iliac, hypogastric, and obturator nodes. Again, we know we can't bill for this separately. It doesn't say when performed, so we don't have that same variability that's out there. So it does make it a little difficult, and this is where I think the payers are pushing back. But my overall in the 600, 1600 times including is used, plus the 440 time includes is used, or excuse me, eight 880 times includes is used, and include is used 441 times. So we've got some variation of includes in CPT distributed throughout the book, with actually nothing in CPT that gives us a real definition of what including means. Does it mean it can't be billed elsewhere? I think that's true. But does it mean you have to do everything in the include, includes, including, or include list? And that's where I have a beef on all this stuff. So my interpretation of this is that the real procedure is pelvic bilateral pelvic lymphadenctomy. That's what needs to be performed, and or at least most of it before we move off that code, because our step down is with lymph node biopsies or the limited pelvic lymphadenctomy. So that's the two choices we have because coding conventions within CPT is you need to pick the most accurate code. And if it needs to be modified, it needs to be modified. So the second piece of this that I would refer to is what does my specialty society say? And according to the treatment of non-metastatic muscle-invasive bladder cancer, and this is the AUA, ASCO, Astro, and SUO guideline, which was revised in 2020 and then again in 2024. When we look at what the definition of a pelvic lymphadinectomy is, the definition here in pelvic lymphadinectomy is when performing a bilateral pelvic lymphadinectomy, clinicians should remove at a minimum the external and internal iliac and obturator lymph nodes. That's what it says at this point in time. So there is nothing in the surgical guidelines here. Now, are we in the right space? Because that wasn't about the prostate, but it is a fairly strong definition of what is the best definition of a pelvic lymphadonectomy that we could find. And this is these are the things that we try and look at is clinically, what really is a pelvic bilateral pelvic lymphadonectomy, because that's the true procedure that's being performed. The includes just is a, I would consider it more or less a guideline of what should be a part of the bilateral pelvic lymphadonectomy, because in in fact, most of the time, there are more nodes taken than just three nodes. It is a series of nodes within tissue that are in those areas. So it's groups of nodes, not just a node here or there. So I would argue on the medical necessity side of things as to what the appropriate node dissection is and clearly document what was removed in that area as a full lymph fatenectomy, not as sampling. If you're taking a node here or a node there, biopsy-wise, then you've got to drop to the 55868. If you couldn't perform the intended medically necessary number of nodes that you wanted to remove, that's a modifier. Could be a 52, could be a 22, depending on if it was more or less work during that particular encounter. So that documentation of that note should really focus on the medical necessity of what you did and focus on the fact that it was a bilateral pelvic lymphatenectomy following guidelines for the treatment of, we would assume in this case, prostate cancer. Ray, any comments, questions?

SPEAKER_00 15:50

Mark, I think that was an excellent explanation. Even I understood it. And the question I have is how does intent fall into this? I went in intending to do a complete pelvic lymphadnectomy, and I took nodes out of a couple of those areas on one side, or all three on one side, and I could only get it on one, maybe two of the other side. So do I still qualify for the full lymphadnectomy? Because that's still a lot more work, and the intent was there and show truly documented that I didn't go in and just do a biopsy on each side.

SPEAKER_02 16:49

So as we've seen through a lot of this stuff, intent is definitely one thing to be considered in all of this. And the reason that you could not complete whatever it was or the election during the procedure to perform a lesser procedure because of what you found doesn't always reflect intent, right? So ultimately, if you went in there and for whatever reason there was a decision that, oh, we're not going to do the bilateral pelvic lymph addenectomy, we're going to pivot and we are going to simply do limited node sampling for this particular patient, then you'd have to drop down to the 55868, right? I mean, there is a procedure code that describes what you did. If you got in there and you were able to do one side of the bilateral pelvic lymphadinectomy, but not the other, because of some medically necessary reason, and you explain that in the operative note, then I think you are closer to the 55869 than you are the 55868 because of what you were attempting to do, but surgically could not, and you elected not to do it based on the medical necessity of that patient during that operation. So it really is about, yes, the intent is a big piece of it, but I think that in the end, it's more about why didn't you do what you intended to do? And the medical necessity should be the driving force that's there, and you want to back it as much as you can with guidelines and opinions from respected sources. This podcast episode is supported by Eurogen, manufacturer of Zesturi. Zesturi, mitomycin for intervesical solution, is indicated for the treatment of adult patients with recurrent low-grade intermediate risk non-muscle invasive bladder cancer. Please visit zesturi.com for more information.

SPEAKER_01 19:13

Would you append a 52 modifier on the 6ix9ine or would you just drop back to the 6'8?

SPEAKER_02 19:22

If you only did one side. Yeah. So I would I don't know what I would do. I would depend on why I didn't do the other side. I would look at it from the standpoint of if it took me a I was trying to do it and I couldn't get there, then I might use a 22, even though I didn't do the full bilateral pelvic, because it was extra effort to do what I did, and I was most of the way there. I was closer to a bilateral pelvic lymphadonectomy than just simply sampling. And that's when the end, I think that's where Ray brought in the question of intent. But that's where it shows that the effort was made to do the bilateral pelvic lymphadenectomy through the effort in the operative note and what it was supported, that's what I'd look for. So I can again I'd have to read the operative note to be sure how I would recommend that. But based on what you're giving me, it sounds like maybe I would use the 55869 and I would Ray, any other comments?

SPEAKER_00 20:34

That was very good. The only thing I would say is the other side of that intent note, if I understand it, Mark, if I intended to do a radical with bilateral lymphaginectomy, and I got in there and I saw everything was so stuck down, I made the decision just to do a biopsy on both sides, then I would have to drop down to the other one because it does say in there somewhere that you do have to charge for the procedure you did. But if my documentation shows I tried, I attempted, and I partially accomplished the job, you're right. I would stick with the line.

SPEAKER_01 21:22

All right, last question on this. This specifically stated Humana. Mark, are you seeing any of these denials coming from others for this?

SPEAKER_02 21:33

So I'm gonna say denial. I'm gonna say on occasion, we've seen things. I think this this is an area where we're starting to see AI push a black and white answer into a gray area. The interpretation of including. As if including means you got to have all three. And we did that. But we can also ask additional questions of your AI tool and say, where did you base this on? And is that a definitive source? Give me an answer from CPT or CMS, and you won't get one. The AI will say, Well, that's a fair point, and they'll get it'll give you some other wishy-washy answer. But it'll come out of the gate swinging with a black or white based on the actually what it reads off the page. And I think that's all the further Humana went, or whoever was running that particular inquest on that note.

SPEAKER_01 22:47

So it's a very valid point that you always quote and preach primary sources versus secondary or additional sources, and you're always very adamant that you back it up with a primary source. So I think that's good advice. And then you can argue with medical necessity and those things with like an AUA source, but that's not a rulemaking body, as you've said many a time, but it certainly is a clinical guidance body. So that's the medical necessity side of things.

unknown 23:30

Yeah.

SPEAKER_02 23:30

I would say it's a primary one step away. So it's kind of like they're part of the development of the code set, so they understand, and this is another one. We're bringing the intent of the code. But the CPT code nomenclature and that structure is it's a decent system. It's a very good system for a lot of things, and we leverage it for all the things that we do. But it is by no means all-inclusive or perfect. I mean, as you can see by the two definitions, there's a gap in clinical procedure between lymph node sampling and bilateral pymphat pelvic lymph adenectomy, and which code you pick to throw the the to report your services, because it covers the majority of what you did with the laparoscopic prostatectomy, and you are doing nodes. So it's probably not worth going to unlisted, but you definitely have got a little bit of boy, does this need a modifier, does it not? Should it just be coded without a modifier? I think those questions are not hard to answer. I remember talking to a couple of folks who were part of the process of developing the 55869. And it was never intended to say that if you didn't take all three of those listed node groups that you shouldn't build the 55869, and you didn't need a modifier. So I've heard it all scales, and of course, we all know that we also have multiple rule makers out there doing the interpretation. And now we've got AI. So we've got ma many more multiples of rulemakers, and anybody putting that opinion out there, and the closest it's gonna get for AI to pull in, that's what it's gonna pull.

SPEAKER_01 25:30

And the five and the difference in payment for the five and five, five, eight, six, eight is not a nominal amount either.

SPEAKER_02 25:37

So it's not it's a couple it's a few hundred bucks. Um and it's mostly in work RVUs. So that's a bigger differential when you're getting paid on work RVUs than it is if you're just getting the full revenue stream. So that's kind of where that sits.

SPEAKER_01 25:59

All right, let's move on to our final question. And again, this came in from one of our attendees at our webinar. And the question was billing a laparoscopic simple prostatectomy, the five five eight six seven with bladder stone removal from the same incision. How do you bill that?

SPEAKER_02 26:23

Yeah, so we know that we've got the five five eight six seven is the simple subtotal laparoscopic surgical prostatectomy, which includes the vasectomy, meatotomy, urethral calibration, endor dilation, and an internal urethrotomy. So nothing about the stones, nothing about actually entering the bladder, which I'm assuming is what we're talking about here, that they're laparoscopically going into the bladder to remove the stone. So we don't see that as an inclusion in the 55867. So now we're going to look at are there any laparoscopic bladder stone removal codes? And there are not many laparoscopic bladder codes to look at. And ultimately, neither of the two that are available specific procedure-wise have bladder stone treatment in them. So in this case, I think you're going to bill a 51999 or an unlisted laparoscopic bladder procedure to do the treatment or to perform the bladder treatment or to bill for the bladder treatment that was performed at the same time as a simple prostatectomy laparoscopic. Ray, question or comments?

SPEAKER_00 27:55

Well, Mark, there is a lithopexy code. So why can't you use it?

SPEAKER_02 28:04

So unfortunately, the 52317 and the 52318 are transurrethral surgeries. They're in the transurrethral section. And even though they don't actually say cystourethroscopy, we would look at that as within that section as transurrethral surgery, and we didn't go transurethral. And as we know and have been told multiple times, laparoscopic, robotic, all those things. Approach matters. That's why we have to use unlisted codes for a cysteomy instead of a straight open cystectomy code. It's location, kind of like real estate.

SPEAKER_01 28:46

All right. Okay, well, let's wrap this episode up here. We want to thank ModMed for supporting this episode. If you're in a market for an EHR or a practice management system, you can go to modmed.com forward slash PRS network for specials for our listening audience. We'd also like to thank Eurogen, manufacturers of Zesduri and Gelmito. For more information, you can go to Zesduri.com or gelmito.com. Okay, let's get some final thoughts. Mark, final thoughts today.

SPEAKER_02 29:19

Well, today was really a a rule and CPT-based discussion, interpretation of language, looking at medical necessity and leveraging all of the tools that are out there, because there there is and will remain a significant amount of gray in this overall process of correctly reporting all the services that are provided for your patients. So I would say don't get stuck in the quagmire of the exact phrasing, but don't ignore it either. I mean, look at intent of code, look at how we can leverage medical necessity and different guidelines across the board to determine what is the best answer for your case if it doesn't follow the line that puts you in the right direction. And then, of course, you've got the secondary piece that we always do, which is that CPT isn't the only rule set. Layered on top of that is CMS and the payers and their interpretations. So making sure you understand where those folks that have the money fall on those interpretations is going to make a difference. So even with our discussion on the 55868 and 69, we gave you the CPT rules. If Humana published a guideline that said 55869 has to include all these three, otherwise you have to use 55868, then you're kind of stuck because of the contract that you agreed to follow their guidelines. So pay attention to all of it, as always. There are layers, kind of like a parfait.

SPEAKER_01 31:12

Can't imagine what's in that parfait.

SPEAKER_02 31:15

I wouldn't want to eat that parfait, but every lack of parfait.

SPEAKER_01 31:19

All right, Ray, final thoughts.

SPEAKER_00 31:22

Well, it all boils down to intent, documentation, and what was actually done. And as Mark says, don't get lost in the weeds because you want to know exactly what you want to charge. And I hope everybody appreciates the depth of research and the argument within himself as to what yes, can I, no, I can't, et cetera, that Mark goes through in coming up with these answers. And so, yes, thanks.

SPEAKER_01 32:06

Yeah, that when we prepare for these podcasts, oftentimes we spend hours discussing the various options and what goes on, and we do the research and spend a lot of time. So so that's that was today's episode. It was a culmination of discussion and research. So all right. Want to remind you that the Urology Advanced Coding and Reimbursement Seminar registration is open if you go to PRSnetwork.com. Right there on the homepage is seminar registration button. And these are the kind of discussions, these in-depth discussions that we have at the Urology Advanced Coding and Reimbursement Seminar. There is always something happening and always something new. And learning from others that are going through this is so important. And through our podcast and webinar, we try and bring you this information, but there's nothing like being immersed in this topic and these questions and with like-minded people for two days, where you get so much more out of that. So we encourage you to join us. It is well worth the time and investment. All right. Also want to remind you that the PRS Coding and Reimbursement Hub, which is available at PRSnetwork.com forward slash urology hub, has a lot of information. And we are adding more and more information and updating that information each week. So keep that in mind. Please, if you're looking at your AI looking for the right information, we've spent a lot of time vetting this information. So you can point your AI at our hub for some of the resources. So we encourage you to do that. Okay. That's all we have for today. We want to thank you all for listening. Take a tile, right?

SPEAKER_00 34:08

Happy coding and willing.

SPEAKER_01 34:15

Thank you for listening to Uralogy Coding and Reimbursement Podcast, where we help urologists and their staff maximize income and efficiency so there's time and energy for patient care and a happy life. Special thanks to our pointer for the music today. You can find this music on Spotify under his record label YouTube.