# Attempted resection pelvic mass



## sidney01@roadrunner.com (Apr 30, 2015)

my physician assisted as well as was lead surgeon with multiple surgeries on one patient. One of the procedures was the above. I cannot figure out what to code this as. Can anyone give me their opinion? Thank you!


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## emcee101 (May 1, 2015)

I think that we will need more info in order to give you any advice. The term "pelvic mass" can mean so many different anatomic locations, types of masses, and different possible surgical approaches that it would be impossible to code without knowing the exact details of the case, as well as which physician performed what part of the procedures. 

Please post your op note and I would be happy to give my opinion. 

thanks!


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## sidney01@roadrunner.com (May 1, 2015)

emcee101 said:


> I think that we will need more info in order to give you any advice. The term "pelvic mass" can mean so many different anatomic locations, types of masses, and different possible surgical approaches that it would be impossible to code without knowing the exact details of the case, as well as which physician performed what part of the procedures.
> 
> Please post your op note and I would be happy to give my opinion.
> 
> ...


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## emcee101 (May 1, 2015)

*Quite the operation...*

This a definitely a complicated case and one that does not come up all that often. I coded urology for 6 years and can't say that I have seen another one like it, although there are a couple that are similar. Your long and complicated procedure warrants a long and complicted response. There are a few things to touch on here with the op note and the codes that you have selected. Hope this helps!

1.) It would be helpful to have the size of the tumor and the physician's opinion as to where the tumor originated.  The size being dictated in the op note will affect code selection on a lot of different tumor and lesion excision CPT codes. It should be your doctor's normal practice to include these in every op note just to be safe and avoid the chance of leaving money on the table. More on tumor size later on...

2.) As far as your code selection, I think you are off base with the codes that you listed. Here's my thoughts why for each code, and the I'll get into my codes as well:
*49000: Explore Laparotomy * - This is only billed when there is not another more involved procedure taking place. Since this is a complicated operation with more than just exploration taking place, this code would not be appropriate.
*49005 ?* - This is not a valid CPT code. I'm not sure if you meant to go with a different code and just mistyped this instead. (If you meant 44005 for enterolysis, it is bundled into all major procecures and cannot be unbundled)
*53500: Urethrolysis, transvaginal, secondary, open, including cystourethroscopy  * - This is for a transvaginal approach to fix the urethra, not an open abdominal surgery on the ureters which is the case with your operation. Different approach, different tube, different anatomic location. 
*51565: Cystectomy, partial, with reimplantation of ureter(s) into bladder  * The main part of this procedure is a partial cystectomy (bladder removal) and this did not occur. 
*99221(25):* E/M billing on the same day as a major procedure is not appropriate except in a very rare instance. This seems like a planned procedure so there would be no rational instance where a separate E/M code should be reported.

3.) I have two CPT codes that I would go with for this proceudre. The order of these codes will change depending on the 4920x code that you use (see below). If 49203 is used it will be the second listed code, but 49204 or 49205 will be the first listed code based on RVU order. In either case, a 51 modifier is needed for the secondary code. 
*50785-LT: Ureteroneocystostomy; with vesico-psoas hitch or bladder flap*This is defined in the op note where the physician severs the ureter at the level of the mass, and then describes how the ureter was reimplanted into the bladder through a cystotomy and with internal fixation. he also notes "A 0 Prolene suture was then placed in the serosa of the 
bladder and into the psoas tendon to allow the bladder to be pulled in 
the direction of the left ureter." which is the vesico-psoas hitch.  Of importance, the ureterolysis is bundled into this code and there is not justification for it to be unbundled. 
*495203-49205: Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors* I listed a range of 3 codes because they depend on size. 49203 is for tumors less than 5 cm in dimeter, 49204 is for tumors 5.1-10 cm iin diameter, and 49205 is for tumors greater than 10.0 cm. You will have to either question the doctor and have them document the size of the tumor in the note, or default to the smallest size and code with 49203. Between 49203 and 49205 there is a difference of 15 RVUs, which will significantly affect the amount that is reimbursed. This translates to a difference of almost $600 that could be left on the table if the tumor size is missing and you have to downcode a case that could have been coded to a bigger size. Also, Your doctor should not need to modify this code because they elected to leave the tumor in place and terminate the attempt at resection. The work was still performed and they deserve to be paid for it. 

As far as an assistant surgeron modifier, I'm not sure your rationale for using modifier 81 which is minimum assistant surgern, when modifier 80 for assistant surgeon is available. All you will do is reduce your reimbursement when there is no reason to. Was the other doctor that performed the surgery truly the primary surgeon and your physician just the assistant, or were they both ascting a primary "co-surgeons"? This is a potential opportunity to use modifier 62: two surgerons if they were acting as co-surgerons and not primary and assistant. In this case, each physician is acting with equal responsibility, and each doctor would require their own op note in order to bill. Instead of getting paid a minimum rate for being the assistant surgeon, each physician needs to increase their billed fee to 125% of the original fee, and then each surgeon is paid 62.5% of the reimbursement, which is also raised to 125% of the normal allowable.


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## sidney01@roadrunner.com (May 1, 2015)

Thank you so very much! I appreciate your advise! As you can tell I am new to urology and needed guidance of a more experienced urology coder. I really appreciate you and your experience!


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