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Urology Coding Alert

Case Study:

Coding When Definitions Overlap

Published on Sat Dec 01, 2001

When a urologist performs multiple procedures at a surgical encounter, proper coding requires choosing between different code sets to arrive at those that most closely describe the work performed. Descriptions for these codes often include more than one procedure.
 
As a simple example of this dilemma, 51595 is a cystectomy with lymph node dissection, while 51596 is a cystectomy with a neobladder. If the urologist performs a cystoprostatectomy with lymph node dissection and a neobladder, the proper coding, taking CPT rules and CCI bundling edits into account, is found below.
 
In a case study of a patient with muscle invasive bladder cancer, the physician, assisted by a second urologist, performed a bilateral pelvic lymph node dissection, a radical cystoprostatecomy, an appendectomy and an ileal neobladder.
 
The recommended filing is:

51596 cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder

55840-51 prostatectomy, retropubic radical, with or without nerve sparing; multiple procedures

50605-50-51 ureterotomy for insertion of indwelling stent, all types; bilateral procedure; multiple procedures. (Code 50605 is bilateral for
ureteroneoenterostomies.)

38770-50-51 pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes; bilateral procedure; multiple procedures.
 
The second surgeon files the same claim with -80 (assistant surgeon) appended to each code.

Problems With Other Code Sets

The urologist can use 38770 because it is not included in 51596, says Margaret T. Atkinson, billing manager for the Center for Urologic Care in Voorhees, N.J. If the urologist used 51595 (cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes), 38770 could not be used because this would be billing twice for the lymphadenectomy. 
 
In the above case study, 55845 (prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes) is not appropriate. The node dissection included with this procedure covers only the obturator fossa bilaterally. The pelvic lymph node dissection performed with radical cystectomy, as represented by 51596, is much more extensive.
 
Although the 55845 states that a full node dissection is performed, most urologists do only a partial node dissection. Several years ago the American Urological Association lobbied Medicare to pay the urologist for the full node dissection, arguing that the operation was valued too low compared to 55840 and that there was no code for radical prostatectomy and the limited node dissection done to clear the obturator fossa. Medicare approved the higherpaying code paying the full node dissection reported for 55845 knowing that the dissection was limited. Because the urologist does a full node dissection for bladder tumors, one should add the code for the full pelvic dissection (38770) knowing that 55845 has been used only for the obturator dissection.
 
If you use 55845 for the radical prostatectomy and the full node dissection, do not also code the node dissection (38770).
 
Code 51596 includes the neobladder, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services in Denver.
 
Although the urologist will have also performed 51010 (aspiration of bladder; with insertion of suprapubic catheter), do not bill it because it is an integral part of 51596. In this situation, 51010 is for a drainage tube placed in the neobladder. The drainage tube is always placed and therefore not payable as a separate procedure, as it would be were it a stent. 

No Modifier -22, No Appendectomy Fee

The operation took more than five hours, but there was no clear indication as to why it took so long, says Page, who does not recommend modifier -22 (unusual procedural services). While the operative report describes scar tissue as "quite extensive," it does not specify this in terms of number of layers. Blood loss, another possible indicator of a reason for modifier -22, is not above normal. This is not an unusually long time for this operation.
 
The appendectomy code is 44950 (appendectomy). Unless the appendix is inflamed or diseased, however, do not bill separately for the appendectomy, Page says. "It's incidental to the operation and not separately billable," she says. Although it is retrocecal, this does not justify billing for its removal. CPT states that "incidental appendectomy during intra-abdominal surgery does not usually warrant a separate identification." If it were necessary to code such an appendectomy, append modifier -52 (reduced services) to 44950, CPT states.

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