# Insurance denying code. Your opinion??



## l1ttle_0ne (Aug 8, 2014)

The insurance is denying the code we used for the pelvic lymph node dissection. They state that the code needs to be changed, that we are under coding for the lymph node part. Can someone please give me their opinion. The primary doctor was paid by the insurance no problem, but now they are denying the doctor that assisted saying that billing the 38571 for that portion of the procedure is wrong. Any opinions??


Date of Surgery: 3/5/2014
Pre-op Diagnosis: Malignant neoplasm of prostate [185]  
Post-op Diagnosis: same  
Procedure:   Da Vinci Assisted Robotic Prostatectomy with Non-Nerve Sparing, Bilateral Pelvic Lymph Node Dissection   
Surgeon:   
Assistants: 
Anesthesia: General
Anesthesiologist:  
Post Procedure Data:
Implants: none  EBL: 350 ml  
Drains: 18 french foley, 19 blake drain  IV Fluids: 2600 ml  




Indication
--year old male who was discovered to have a prostate cancer diagnosed 12/2013.  PSA was 16.8 in 12/2013 and he underwent TRUS PNB 12/12/2013. He was found to have G6-7 adenocarcinoma in 9 of 14 cores. TRUS volume was 32.4 g, and there was right sided induration. By MSK nomogram, his probability of organ confined disease is 31%, probability of extracapsular extension 55%, seminal vesical invasion is 25%, and lymph node involvement is 7.5%. His progression free probability after prostatectomy is 78% at 5 years and 68% at 10 years with a probability of cancer specific survival is 99% at 5 years and 98% at 10 years. His progression free probability after brachytherapy at 5 years is 69%
 The pros and cons of the surgery were discussed with the patient. We reviewed the possible side effects and complications of surgery which include bleeding, bowel injury, rectal injury, stroke, heart attack, inability to remove cancer completely, urinary incontinence, and impotence. The patient understands and consents for surgery.


Findings    
Non nerve sparing prostatectomy, no bladder neck tailoring needed.  Bilateral pelvic lymph node dissection, left side was more adherent to the iliac vein, and thus to avoid damage to the vessel, less of the packet was taken on the left side.  


DETAILS OF PROCEDURE: The patient was brought to the operating suite where he was lay supine on the table. IV antibiotics were given, and sequential compression devices were placed on both extremities.   He was given general anesthesia and endotracheally intubated. The arms were padded and tucked to the sides and the legs were placed in the split leg table and supported.  The abdomen was shaved and the abdomen, genitalia and mid thighs were sterilely prepped and draped He was prepped and draped in the usual fashion. A Foley catheter was placed in his bladder through his penile urethra.


A Veress needle was used to induce pneumoperitoneum in the left upper quadrant.  A 12 mm trocar was placed in the midline just above the umbilicus and two da Vinci trocars were placed in the left lower quadrant while a da Vinci trocar and assistant trocar were placed in the right lower quadrant.  The patient was placed in the Trendelenburg position and the robot was brought in and docked to the trocars.




A 0-degree laparoscope was inserted into the abdomen and the abdomen was inspected.  
The scissors and Maryland graspers were attached. The space underneath the bladder and rectum was opened using scissors and the vas deferens was identified. The vas deferens on the right was traced to the seminal vesicle, and the seminal vesicle was dissected completely free. The lateral aspect of the seminal vesicle was cauterized and ligated. On the left side, the same procedure was performed. Clips were used on the lateral aspect and this was to preserve the neurovascular bundle somewhat. The Denonvilliers fascia was opened in the midline. The anterior aspect of the bladder was then dissected free and the bladder was dropped. The prostate was exposed. The periprostatic fat was dissected and removed. The endopelvic fascia was opened sharply and the right side taken down from the base proximally to the apex. The same was performed on the left side. The apex of the prostate was carefully dissected free. The puboprostatic ligaments were transected. The superficial dorsal vein was bipolared and transected.  The dorsal venous complex was divided with a stapling device, with excellent control of the complex.


The bladder neck was dissected from the prostate. The urethra was exposed in the midline and the bladder neck was teased away from the prostate on the right and left side. All bleeders were fulgurated. The urethra, as well as the bladder, was incised, and the Foley balloon was deflated and the Foley brought through the incision. The Foley was lifted to expose the posterior aspect of the bladder neck. The posterior bladder neck was dissected and, behind this, we were able to identify the vas and the seminal vesicles.


The left neurovascular bundle was then teased and dissected away from the prostate posteriorly. Hemolok clips were used to stop bleeders at the proximal aspect of the pedicle. The same clips or Bovie was used in the pedicle or on the bundle. 


This exposed the prostatic pedicles and these were taken down with the hemolok clip device on both sides.  This allowed dissection to be carried up to the prostatic apex.


The same was performed on the right side. The prostate was connected only by the urethra. The urethra was transected sharply, and the prostate was freed and placed in an Endopouch.  There was no significant bleeding from the neurovascular bundles and the bladder neck was large.  This was reconstructed using 3-0 Polysorb suture.
A Rocco stitched was applied using a 3-0 Vicryl.  The bladder neck was anastomosed to the urethra. A continuous stitch was used to anastomose the bladder to the urethra with a 3-0 V lock stitch. The initial stitch was placed in the bladder at 5 o'clock in an outside-in fashion. Then the stitches were placed in the urethra in an inside- out fashion at 5 o'clock. The suture on the left side was continued in a simple continuous fashion going from 5 o'clock to 10 o'clock in a counterclockwise method. The same was performed on the right side from 5 o'clock to 10 o'clock in a clockwise method. A new 18-French Foley catheter was placed. It was irrigated and there was no leakage. The sutures were then tied.  
A pelvic lymph node dissection bilaterally. The boundaries were the iliac vein, the sidewall, and the obturator nerve. A bipolar or hemolok clips were used to stop any bleeding. The lymph nodes were removed for pathology.  
The robot was then undocked. The ports were removed. The prostate was removed in the midline port. The fascia was closed using 2-0 Vicryl in a subcuticular fashion in the 12 mm port. The skin was closed using 4 0 Monocryl in subcuticular fashion. We then placed steristrips  over the incision. The needle and sponge counts were correct. The patient tolerated the procedure well without complications.


Operative Time: 5 hours


Specimen:  Prostate, seminal vesicles bilaterally, bilateral pelvic lypmph node packets


Counts: Instrument, sponge, and needle counts were correct prior to closure and at the conclusion of the case.


Disposition
The patient was taken to Recovery Room in good condition.


Complications  
No complications


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## nateich (Aug 8, 2014)

I am sort of confused on what you are asking, I'm sorry. It sounds like there was a primary surgeon and an assistant who is a physician, if that is the case I would have coded:
Primary Surgeon:
55866
38571
Assistant:
55866-80
38571-80

I'm not sure if that is what your asking, but please feel free to elaborate so that I can understand your particular situation. I do not feel that you have under coded...


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## teresabug (Aug 9, 2014)

If the 2nd surgeon was of a different specialty i believe you would bill with mod 62, otherwise I agree w/ the above post.


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## l1ttle_0ne (Aug 11, 2014)

Sorry, I was just wondering if everyone agreed with the billing of the 38571. Because Humana is denying the assistant's 38571 (even though they paid the primary surgeon with no problems.) They are telling us that the 38571 is not  the correct code that should have been billed. That we are under coding. But all of us here at work thought it had been billed correctly. So I was just wanting some other opinions. Both surgeons are the same specialty. Thanks for your help. Sorry I wasn't more clear.


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## nateich (Aug 11, 2014)

Thank you for additional info; did asssitant assist with 55866? Did you bill and get paid for that code for the assistant?


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## l1ttle_0ne (Aug 11, 2014)

Yes the assistant did assist with both procedures. The 55866 was paid for the assistant, just not the 38571.


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## nateich (Aug 11, 2014)

So strange for Humana to deny that code, as I am sure you are thinking as well.  

Unfortunately, someone will have to appeal or sit on the telephone for a couple of hours to get this one corrected and paid. 

Best of luck.....


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