General Surgery Coding Alert

Focusing on the type of procedure is a great place to start.

It’s essential to thoroughly examine the medical records when your surgeon performs adrenalectomy procedures. Details such as the technique applied and the presence of any complications or pathological conditions like adrenal tumors should be noted, and extra work should be accounted for.

So, how prepared are you to code these procedures? Take this quiz and assess your understanding of adrenalectomies.

Question 1: How should you code for a laparoscopic adrenalectomy?

Answer 1: CPT^® 60650 (Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal).

Take note: Don’t assume, however, that your physician will automatically use a laparoscopic approach. Verify by double-checking the operative report and then choosing the correct primary code.

Question 2: Which code should you choose for an open adrenalectomy?

Answer 2: You should choose code 60540 (Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure)).

Tip: CPT^® codes typically distinguish tissue removal procedures by surgical approach such as open, laparoscopic, core needle, etc. An adrenalectomy is tissue removal, and that is why

you’ll find the 60650/60540 distinction for adrenal glands. Unlike surgeries involving other organs, CPT^® doesn’t differentiate between resection and biopsy for adrenal tissue. The descriptors for both 60650 and 60540 describe an “adrenalectomy, partial or complete” or “exploration of adrenal gland with or without biopsy.” That means you’ll choose one of these codes whether the surgeon simply “explores” the adrenal gland or removes the entire organ.

“It is quite important to pay close attention to the operative report since there are several CPT^® codes to choose from when reporting adrenalectomy”, says Stephanie Stinchcomb Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime coder and consultant in Glen Burnie, Maryland. “The approach of the procedure is very important in selecting the correct CPT^® code. Also pay attention to what is actually performed during the surgery,” she adds.

Question 3: You would use 60545 (Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor) when an adrenalectomy and a retroperitoneal mass excision are performed. If the surgeon opts for a laparoscopic method, can you apply 60650 to both the adrenalectomy and the mass excision?

Answer 3: Code 60650 does not include the removal of an associated retroperitoneal mass like 60545 does. Instead, you should choose one of the following:

Option 1: To indicate the extra work associated with excision of a contiguous retroperitoneal mass, consider adding modifier 22 (Increased procedural service) to code 60650. The surgeon needs to clearly document the extra work and time spent on the removal. “The documentation is an important part in order for the additional payments with the modifier 22” according to Storck

Option 2: You can instead consider adding the unlisted codes 49329 (Unlisted laparoscopy procedure, abdomen, peritoneum and omentum) or 60659 (Unlisted laparoscopy procedure, endocrine system) to your 60650 claim to describe the extra dissection and surgical work performed. Again, the surgeon will need to provide detailed documentation. “If there is no specific CPT^® code that reflects what the surgeon did during the procedure, using an unlisted procedure code is appropriate depending on the location of the body where the problem is,” says Storck.

Remember: “Claims submitted with a modifier 22 or with an unlisted procedure code will trigger a manual review of the claim. Expect delays in claims processing,” says Storck.

Question 4: Should the services be coded separately when a surgeon performs an adrenalectomy that involves work on the adrenal gland and another organ, like the kidneys?

Answer 4: No, you should not separately report an adrenalectomy with a procedure like 50545 (Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota’s fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy)) because the code descriptor already includes the adrenal gland removal. Also, Medicare’s National Correct Coding Initiative (NCCI) bundles an adrenalectomy into a simple nephrectomy, which doesn’t include removal of Gerota’s fascia or lymphadenectomy. In fact, NCCI bundles both the open and laparoscopic adrenalectomy codes with all nephrectomy codes.

Keep in mind: All radical nephrectomies, whether open or laparoscopic, include an adrenalectomy. However, if code 50545 is the major procedure and the physician doesn’t remove the adrenal glands, there is no reduction considered, and adding modifier 52 (Reduced services) is not required.

Question 5: How would you code a situation where a surgeon carries out a left adrenalectomy and a partial upper pole nephrectomy on the left kidney due to the invasion of adrenal cancer, considering that the adrenalectomy is included in the radical nephrectomy?

Answer 5: NCCI edits bundle the two procedures. Code 50240 (Nephrectomy, partial) includes the work for 60540. For this operative session, you would submit only 50240 for both procedures. “However, the NCCI indicator for 50240 and component CPT^® code 60540 is a ‘1’; that means if the procedure can be considered separate, identifiable and documented completely in the surgical note, the 60540 may be reported with the modifier 59 (Distinct procedural service),” adds Storck.

Question 6: If the surgeon removes a lymph node or nodes in addition to an adrenal gland, should you code this separately?

Answer 6: Yes, you may be able to separately code the procedure using a code such as 38564 (Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic)) or 38570 (Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple), depending on the approach.

Don’t lose funds: Failing to account for additional procedures like a 38570 lymph node dissection performed alongside a 60650 lap adrenalectomy could lead to financial losses for your practice. Even though your payer will apply a multiple-procedure payment reduction on the second scope procedure, it’s important not to overlook the extra compensation you’re entitled to.