This article covers Chapter VII of the National Correct Coding Initiative (NCCI) Policy Manual and addresses a few of the guidelines pertaining to surgical procedures related to the urinary, male genital, female genital, maternity care and delivery systems focusing on the CPT code range 50000-59999. The information presented will be selected highlights from Chapter VII, therefore, you may wish to refer to the NCCI Policy Manual for additional and more complete information.
As a reminder, start by following the CPT guidelines, information within the code descriptors and parenthetical notes. For facility reporting on behalf of Medicare beneficiaries refer to the NCCI Policy Manual for Medicare, which can be found on the Centers for Medicare and Medicaid Services (CMS) website at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd.
It is important to report the HCPCS/CPT code that most accurately describes the procedure performed. It is not appropriate to report a code if all of the services described by that code are not performed. It is also not appropriate to unbundle by reporting multiple codes in place of a single HCPCS/CPT code that describes all of the services.
- Insertion of urinary bladder catheters may not be separately reported when performed at the time of, or just prior to, a surgical procedure. The placement of urinary bladder catheters is considered inherent to the primary procedure. This includes procedures that involve the placement of a urethral/bladder catheter for postoperative drainage.
- CPT code 52204, Cystourethroscopy, with biopsy(s), includes all of the biopsies obtained during the procedure. Therefore, it is only reported one time no matter how many biopsies are taken.
- When a code descriptor in the genitourinary system includes hernia repair, for example CPT code 51500, Excision of urachal cyst or sinus, with or without umbilical hernia repair, it is not appropriate to additionally report the hernia repair unless it is performed at a different site through a separate incision.
- CPT code 51700, Bladder irrigation, simple, lavage and/or instillation, may be assigned to report irrigation with therapeutic agents or when performed as an independent therapeutic procedure. It may not be separately reported when part of a more comprehensive service, for example to gain access to, or visualize the urinary system. In addition, CPT code 51700 may not be reported for irrigation of a urinary catheter.
- When reporting endoscopic procedures, all minor related components are included and not reported separately. The example provided in the NCCI manual pertains to transurethral resection of the prostate (TURP). A TURP includes meatotomy, urethral calibration and/or dilation, urethroscopy, and cystoscopy. Therefore, it is not appropriate to separately report the included procedures.
- Procedures that involve ureteral anastomoses (for example, CPT code range 50740-50825, 50860) are generally mutually exclusive and would not be reported together. One example of an exception to this guidance is if one type of anastomosis is performed on one ureter and a different type of anastomosis is performed on the contralateral ureter. In that case, it would be appropriate to report both procedures utilizing laterality modifiers (e.g., LT, Left Side and RT, Right Side).
- Insertion of a self-retaining indwelling stent during cystourethroscopy with ureteroscopy and/or pyeloscopy, captured with CPT code 52332, Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type), may not be reported for the insertion and removal of a temporary ureteral stent when performed during a diagnostic or therapeutic cystourethroscopy with ureteroscopy and/or pyeloscopy.
- When a ureteral stent is inserted at an anastomosis of a ureter and another structure in order to maintain patency, or if a ureteral stent is inserted when the ureter is incised during a procedure, the insertion of the stent is inherent to the primary procedure and may not be additionally reported.
- The CPT codes that capture litholapaxy (CPT codes 52317-18) are reported for crushing/fragmentation and removal of calculus in the urinary bladder; but not when the calculus is the result of a procedure to remove, manipulate, and/or fragment calculi higher up in the urinary tract.
Male genital system
- Puncture aspiration of a hydrocele, CPT code 55000, Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication, may not be reported with inguinal hernia repairs and with services that involve the tunical vaginalis and proximal anatomy, for example the scrotum and vas deferens.
- There are several CPT codes (for example, 52601-52649, 53850-53855, 55801-55845, 55866, and 55880), that describe various methods of removing or destroying prostate tissues. As these codes are mutually exclusive, it is not appropriate to report two codes from this range together.
Female genital system
- When assigning codes for pelvic exenteration procedures that include multiple structures, (for example, CPT code 51597, Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of bladder and ureteral transplantations, with or without hysterectomy and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof), it is not appropriate to separately report the removal of individual structures.
- If a vaginal hysterectomy is accompanied by additional dissection to repair a rectocele (with perineorrhaphy if performed) or cystocele (with repair of urethrocele if performed) or a combined anteroposterior colporrhaphy to repair a rectocele and a cystocele, it may be appropriate to report CPT codes 57250, Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy, or 57240, Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed, or 57260, Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed;, with the code for a vaginal hysterectomy. In these examples, the correct NCCI PTP-associated modifier would be appended.
- It is not appropriate to report colpopexy codes (CPT codes 57282-83) to additionally report normal fixation of the vagina to surrounding tissues when performed with a vaginal hysterectomy. Only if a more extensive colpopexy is performed consistent with the requirements of CPT code 57282-83 is an additional code with the use of the appropriate NCCI PTP-associated modifier allowed.
Below are a few Questions and Answers to illustrate the above guidance:
Based on the documentation submitted, assign CPT code 54640, Orchiopexy, inguinal approach, with or without hernia repair.
It is not appropriate to additionally assign CPT code 49500, Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible, as the hernia was repaired through the orchiopexy incision. Only if the hernia was repaired via a separate incision/different site could a code for the hernia repair be additionally reported.
During a laparoscopic hysterectomy, bilateral ureteral stents were placed for intraoperative identification of both ureters. A catheter was used to cannulate the left and right ureteral orifices and both stents were brought out of the meatus. A Foley catheter was then placed. Both open-ended catheters were then secured into the Foley catheter. The Foley catheter and bilateral ureteral stents were removed at the conclusion of the surgical encounter. In the outpatient setting, can the placement of intraoperative ureteral stents be reported in addition to the laparoscopic hysterectomy?
It is not appropriate to assign a code for the insertion of intraoperative bilateral ureteral stents. Per the medical record documentation, the stents were placed to identify the ureters to protect them during the primary surgical procedure. The insertion and removal of temporary stents in this example are not additionally reported.
A patient presented with ureteral calculus that migrated into the bladder. A cystoscope was placed into the bladder and the stone was removed. Following the removal of the calculus, retrograde pyelogram of the ureter was performed to make sure there were no additional ureteral stones. Although there is an edit that prevents reporting both CPT code 52310 and 52005, can both be reported when calculus is removed from the bladder but the retrograde pyelogram is performed to visualize the ureter?
Assign CPT code 52310, Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple, for removal of the stone. CPT code 52310 represents the primary procedure and is designated as a “separate procedure.” It is not appropriate to additionally assign CPT code 52005, Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service;, for the retrograde pyelogram to check the ureter for additional calculus following removal of the stone from the bladder.