Urology Coding Alert

Key: Your secondary diagnosis will help get your claim paid.

Any number of reasons can cause a urologist to decide that he must abort a planned laparoscopic nephrectomy in favor of an open nephrectomy. But that conversion can throw a real wrench in your coding. Do you report the laparoscopic code? The open code? Maybe both the laparoscopic and the open codes?

Take a look at this case study and determine how you would code it. Then review the expert guidance to see if you would have received the money your urologist deserved or if you would be facing a denial.

Scenario: A patient has a renal tumor. The urologist brings the patient to the operating room to perform a laparoscopic radical nephrectomy. During the procedure, however, the patient experiences excessive blood loss. As a result, the urologist decides to convert to an open approach to control the bleeding and then to proceed with an open radical nephrectomy.

Forego the Laparoscopic Code For Medicare

In this case, the patient has undergone a failed laparoscopic nephrectomy, which has been converted to an open nephrectomy. For Medicare and many other payers you will report just the open procedure code: 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy).

Here's why: If during a laparoscopic procedure, the surgeon converts to an open surgery, you should only report the open procedure, according to CPT® and CMS guidelines. When one approach to a procedure fails and the surgeon must change to a second approach, "these procedures are considered 'sequential procedures,'" according to the National Correct Coding Policy Manual for Part B Medicare Carriers, version 10.3. The manual also states, "Only the CPT® code for one of the services, generally the more invasive service, should be reported."

"According to coding policy, one should code the open procedure code, not the laparoscopic," confirms Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. "So, in this case, most often when you have a failed laparoscopic radical nephrectomy, and you convert to an open radical nephrectomy, you should use CPT® code 50230."

Pointer: If the time it takes your urologist to perform the surgery is excessively prolonged due to both the laparoscopic and open approaches used, you should consider appending modifier 22 (Increased procedural services) to 50230.

"Sometimes attempting to perform a laparoscopic nephrectomy and then converting to an open procedure, you spend a great deal of time really performing more than one procedure," Ferragamo says. "This causes an increased time factor. If that's the case, you may want to bill the 50230 with modifier 22."

By adding modifier 22 to the open procedure code, you can account for the additional time your urologist spends attempting the procedure laparoscopically before having to convert to open. To add modifier 22, the operative report must show that your urologist performed work that was above and beyond the time and work normally required for the procedure.

Don't overlook: If your urologist documents that he did a diagnostic laparoscopy and he indicates in the operative report that the diagnostic laparoscopy led him to then perform an open nephrectomy you can bill the open nephrectomy (50230) and the diagnostic laparoscopy (49320, Laparoscopy, abdomen, peritoneum, and omentum, diagnostic ...) with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended to 49320.

"In this case the laparoscopic procedure was diagnostic not therapeutic, and because the laparoscopic findings led the urologist to believe that an open procedure would be more appropriate, he then performed the open procedure: the open radical nephrectomy," Ferragamo explains.

Support Your Claim With 2 Diagnosis Codes

The primary diagnosis for this patient should be the medical necessity or the reason for the nephrectomy: the renal tumor (189.0, Malignant neoplasm of kidney and other and unspecified urinary organs; kidney, except pelvis).

Additionally: You also need to report as a second diagnosis V64.41 (Laparoscopic surgical procedure converted to open procedure), which "indicates that a laparoscopic procedure was converted to an open procedure," Ferragamo says. Using V64.41 does not affect the primary diagnosis.

Change Your Coding For Some Private Payers

Some non-Medicare payers may actually reimburse you for both the open procedure and the attempted laparoscopic procedure so you should check with your payer before choosing which codes you will report.

If your payer allows you to report both procedures, you should first report the open procedure with 50230. Then bill 50545 (Laparoscopy, surgical; radical nephrectomy [includes removal of Gerota's fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy]) for the laparoscopic nephrectomy.

In this case, because the urologist discontinued the laparoscopic procedure due to excessive bleeding, you should append modifier 53 (Discontinued procedure) to 50545 since your urologist converted to the open procedure for the well-being of the patient.

You might instead append modifier 52 (Reduced services) to 50545 to indicate that your urologist didn't complete the laparoscopic nephrectomy and terminated the procedure at his own discretion.

The difference: You should use modifier 52 when your urologist, while performing a service or procedure, chooses to partially reduce or eliminate a portion of the code's requirements. You will use modifier 53 when your urologist ends a procedure due to a threat to the patient's well being or other extenuating circumstances.

Tip: Let the payer reduce the fee for the procedure when you use modifiers 52 and 53. Do not apply the fee reduction on the claim. If you do, the payer may still reduce your reimbursement because of the modifier, and you may then receive a double fee reduction, Ferragamo explains.

Don't miss: Remember, also, to add modifier 59 (Distinct procedural service) to 50545 because most laparoscopic procedures are bundled into the open procedure coding.