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 [...]
