One of my colleagues tells me that he is billing a urethral suspension at the same time he does his laparoscopic radical prostatectomy and is getting paid by Medicare. That seemed too good to be true since a suspension could be performed on every patient. Is it OK to bill a suspension with a radical prostatectomy?
Good question. Unfortunately, it deserves several answers. According to the National Correct Coding Initiative (NCCI), Medicare’s bundling edits, the two codes (55866 – Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed) and 51990 (Laparoscopy, surgical; urethral suspension for stress incontinence) are not bundled and can be charged together without a modifier.
However, we have several concerns about billing for the urethral suspension at the same time you perform a radical prostatectomy in a patient who did not have a preoperative incontinence problem necessitating the suspension. First and foremost, by law, Medicare cannot pay for preventive services unless specifically enacted by Congress. That means Medicare could ask for their money at a future date if a record review resulted in the determination that the service was not medically necessary at the time the service was performed.
The AUA has also reviewed this issue and indicated in a Policy and Advocacy Brief published May 3, 2017 that reporting the suspension with a prostatectomy should be reserved for those patients with an existing diagnosis of incontinence.
Considering both the current policy interpretation risk and the AUA position, we feel it’s important to highlight the concern for future bundling edits. If a high percentage of the radicals are billed with urethral suspension, then it is likely to be bundled in the future and it is possible that it will be tagged with an indicator that will not allow unbundling, closing the door on appropriate billing for those patients with existing incontinence.
Consider this similar situation: Initially, 51800 (Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck [anterior Y-plasty, vesical fundus resection], any procedure, with or without wedge resection of posterior vesical neck) was not bundled with 55845 (Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes), and many physicians were billing the two together. Currently, they are bundled and cannot be unbundled.
In summary, yes, the two procedures can be billed and should be paid. However, we recommend you do not bill, unless the patient has incontinence and the need for the suspension prior to surgery.
My question is about the use of the −59 modifier. I was taught that if two procedures were performed and the bundling edits stated they could be billed with the modifier, you should add the modifier in order to get paid. My understanding from a friend who attended your seminar is that just because the bundling edits indicated you could unbundle with the modifier does not mean that you always should unbundle with a modifier. What is correct?
Codes that are included in the NCCI bundling edits with an indicator “1” allow for unbundling if circumstances support that the service is distinct. The computer recognizes that there is special circumstance only if the modifier is appended to the code.
The NCCI is developed using Medicare data with review by a contracted entity. In order to add a modifier to any procedure, the documentation should clearly indicate that the procedure meets the definition of the modifier. Private payers may use modified versions of the NCCI data with additional restrictions or allowances.
The −59 modifier CPT definition is as follows:
Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier −59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
Breaking down the definition, there are five separate circumstances in which modifier −59 should be used: different session on the same day, different site or organ system, separate lesion or injury, separate incision/excision, or different procedure or surgery.
Medicare does not pay for a different procedure or surgery—this is one of the reasons, therefore, that we recommend that you use the −X (E, S, P, or U) modifiers for Medicare:
- XE: Separate encounter
- XS: Separate structure/organ
- XP: Separate practitioner
- XU: Unusual non-overlapping service.
As with most coding discussions, it all starts with documentation supporting the services billed. If the operative note does not clearly support one of the definitions above, any denial will be difficult to appeal and once a payer determines that the practice is not appropriately using the modifiers reported, more denials will follow.
Therefore, in our seminars we teach that documentation and circumstances noted must drive correct coding. If the second procedure is a component of the first procedure, is performed to facilitate the first procedure, or the documentation does not support one of the five definitions of the circumstances by which it should be used, then you should not charge for the second procedure with a modifier even if it is allowed by the NCCI.