Urology Coding Alert

Tip: Scrutinize documentation so you don’t miss reporting additional procedures

When urologists perform radical nephrectomies, there’s no cookie-cutter way to report each procedure. Look at the factors and services leading up to the surgery to make sure you’re not oversimplifying the coding process and missing additional codes you should be reporting.

Report Biopsies That Lead to Surgery

Urologists may perform a radical nephrectomy after they perform a renal biopsy that reveals a malignant tumor. Your key to capturing payment for the biopsy and the nephrectomy procedure is modifier 59 (Distinct procedural service).
 
If a positive pathology report on a frozen section leads your urologist to perform a radical nephrectomy, you should report 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy) and 50205-59 (Renal biopsy; by surgical exposure of kidney; Distinct procedural service), says Christy Shanley, CPC, billing manager for the University of California, Irvine department of urology.
 
Reasoning: Modifier 59 overrides the National Correct Coding Initiative edit that considers 50205 to be a component procedure of CPT 50230. You should unbundle the renal biopsy from the radical nephrectomy because the biopsy was a separate procedure, the results of which led to the decision for a nephrectomy.
 
Tip: If your urologist also performs an adrenalectomy, NCCI Edits, as well as the American Urological Assoc-iation, say you can’t separately report that procedure in addition to the nephrectomy.

Code Both Partial and Radical When Appropriate

When a frozen section of a removed portion of the kidney (partial nephrectomy) reveals incomplete removal of a tumor, your urologist may then decide to perform a radical procedure and completely remove the remaining portion of the kidney during the same surgical session. Your challenge is deciding whether you can report both procedures or just one.
 
Under these circumstances, remember that the urologist decided to perform a radical nephrectomy based on the pathology report of the partial nephrectomy specimen. When your physician performs a radical nephrectomy after already performing the partial, you should code both. And you should also expect to be reimbursed for both services because the National Correct Coding Initiative does not bundle these two procedures.
 
Bottom line: Report both 50240 (Nephrectomy, partial) and 50230 together. Append modifier 51 (Multiple procedures) to 50230 to show the carrier that your urologist performed the two procedures during a single surgical encounter in the same area of the body and that they should be separately reimbursed.
 
Report 50240 as the primary procedure because this procedure has higher RVUs and pays more than 50230, which you should submit as the secondary procedure.
 
Tip: For Medicare patients, you don’t need to append modifier 51 because Medicare will append it for you, but note that any code with modifier 51 is subject to Medicare’s multiple-procedures payment rule, which reduces the fee for the procedure by 50 percent.
 
Some payers may ask that you append modifier 59 to 50230 to paint a picture of how both surgeries came about.

Only Use 50010 When There’s No Other Procedure

When your urologist performs a renal exploration and then decides it’s necessary to perform a radical nephrectomy, you may be tempted to report both the surgical procedure and the exploration. You’re setting yourself up for denials if you bill for both, however.
 
In this case, report only 50230 for the radical nephrectomy. By definition, you should not use the renal exploration code (50010, Renal exploration, not necessitating other specific procedures) under these circumstances. When your urologist performs a nephrectomy, renal exploration is an integral part of the procedure and should not generate a separate charge.
 
Beware: Even though the renal exploration led to your physician’s decision to perform surgery, don’t make the mistake of appending modifier 57 (Decision for surgery) to 50010 and trying to report it separately. You can only use modifier 57 on E/M service codes, and you would only use it if the urologist made a decision for surgery during an E/M visit, says Tina Miller, CPC, with Urology Associates of Central California in Fresno.