Urology Coding Alert

Get useful tips and billing advice on your way to the correct code set.

There are plenty of ways to get tripped up working within your own specialty, but a difficult coding scenario can be compounded ever further when the procedure at hand extends across two or more medical fields. When it comes to urology, there are some instances when a procedure to treat an underlying urinary condition can involve organs typically treated by providers in the gynecological specialty. When these specialties overlap, it’s your duty as a coder to get to the bottom of all the intricate coding details.

In the following clinical encounter, you will need to summon knowledge spanning from coding concepts to medical terminology in order to get to the heart of the answer. As you’ll see, you should also be wary of reporting an all-encompassing code unless it accurately represents your surgeon’s work.

Tag along to work your way through this detailed urogynecological coding example.

Break Down Each Respective Procedure

Code this: A laparoscopic robotic-assisted radical cystectomy that includes a total abdominal hysterectomy with a bilateral salpingo-oophorectomy, a partial vaginal resection, and a bilateral complete pelvic lymph node dissection

You’ll initially run into some trouble when considering what code works for a robotic-assisted radical cystectomy procedure. You code a traditional complete cystectomy with 51570 (Cystectomy, complete; (separate procedure)). However, that code is only applicable to open procedures that involve the removal of the bladder. A radical cystectomy, when performed on a female patient, will typically include the removal of the uterus, ovaries, and a portion of the vagina.

Coder’s note 1: The operative report involving a robotic-assisted cystectomy will include an initial incision and the advancement of a camera. The surgeon will place a series of robotic ports before docking the robot and beginning the procedure.

For robotic-assisted complete or radical cystectomies, your only option is to report unlisted code 51999 (Unlisted laparoscopy procedure, bladder) since the surgeon performed the robotic-assisted surgery via a laparoscopic approach. However, keep in mind that this unlisted code will only represent the component of the radical cystectomy that’s performed on the bladder. This means that you’ll be reporting the remaining services separately.

For this portion of the service, you must identify a proper comparison code and making a comparative percentage determination. For instance, the provider may conclude that performing a complete cystectomy laparoscopically results in 25 percent more work than the most comparable open procedure code, 51570. However, you must also take into account the numerous services normally included within the radical cystectomy that you’re coding for separately. This should ultimately result in less reimbursement for 51999 than its 51570 counterpart.

Remember: When submitting an unlisted code to the respective payer, you should not only submit the claim on paper, but also include the most appropriate comparison code in Box 19 of the CMS-1500 form. “That’s because you want to give the payer a reference for valuing the service,” explains Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey. “It is best to give them a CPT^® code to compare it to along with an estimated percentage comparing the work done between the established CPT^® code and the unlisted code.”

Avoid Pitfalls Coding Remaining Services

Since you are coding the radical cystectomy using an unlisted bladder procedure code, you must also consider how to report the rest of the services. While your initial inclination may be to report codes for each respective service, you should first look for any combination codes for the following supplementary procedures:

• Total abdominal hysterectomy,
• Bilateral salpingo-oophorectomy,
• Partial vaginal wall resection, and
• Bilateral pelvic lymph node dissection.

Note 1: When examining procedure codes that involve a salpingo-oophorectomy, the code description should include the following: “with or without removal of tube(s), with or without removal of ovary(s).”

Note 2: With respect to this clinical scenario, the term dissection is interchangeable with excision when you’re looking for a code for the bilateral pelvic lymph node dissection. You can also verify this within the body of the operative report by pinpointing the portion of the surgery that involves removal of lymphatic vessels and tissue using a bipolar and/or monopolar cautery.

Armed with that knowledge, you can now work your way through the CPT^® code options. You may initially come across a single, all-encompassing code that seemingly fits the bill for each of the aforementioned services. For instance, have a look at the code description for code 58200 (Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s)).

Pointer: You’ll see that 58200 includes a variety of services in addition to a total hysterectomy, but you’ll want to consider the advice of Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook to understand why this particular code doesn’t align with the clinical encounter.

“Despite the fact that the surgeon documents a bilateral pelvic lymph node dissection in their operative report, this dissection is more extensive than a ‘para-aortic and pelvic node sampling,’ as indicated in 58200. Furthermore, you should also note that 58200 is an open procedure code whereas the remaining procedures in this scenario were performed via laparoscopic and robotic techniques.”

Correct coding: Therefore, instead of 58200, Ferragamo explains that the following codes more accurately describe this clinical scenario:

• 58571 (Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)) or 58573 (… for uterus greater than 250 g...)
• 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy)

Lastly, while you should typically include a partial vaginectomy as a component of the radical cystectomy, the fact that your unlisted procedure is detailed as a bladder procedure means you should code the partial vaginectomy separately as well. You’ll report this procedure using 57106 (Vaginectomy, partial removal of vaginal wall).