Urology Coding Alert

Choose Precise Codes for Multiple-Procedure Surgeries

Published on Tue Jan 01, 2002

When billing for multiple procedures, urologists must often choose between codes that may include more, or less, than the service performed. Some CPT codes include many different procedures, but not the precise combination done during a specific surgery. Two case studies and how to code them will be reviewed one of a TURP, one of a nephropexy.

Prostate case study: The urologist performs a cystoscopy, evacuation of blood clots, a left retrograde catheterization and stent, electrode resection of the prostate and removal of radioactive seeds from the prostate.

Use 52601 (transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) for the procedure. Use 52332 (cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) with modifier -51 (multiple procedures) for the stent, which includes the retrograde catheterization. If you read the retrograde, use 74420 (urography, retrograde, with or without KUB) with modifier -26 (professional component). Removal of the radioactive seeds is 52310 (cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple), but this is bundled with 52332 and can never be unbundled, says Laura Siniscalchi, RHIA, CCS, CCS-P, a consultant with the Boston branch of the auditing firm Deloitte and Touche.

This is a timely case study because there is also a new code for evacuation of clots 52001 (cystourethroscopy with irrigation and evacuation of clots). However, it's too soon to say whether it will be bundled. Last year, 52601 would have included clot evacuation. It is not bundled in the new CCI Edits.

Code the claim as follows:

52601

52332-51

52001-51

74420-26.

If the payer is commercial, you can also use 52310 (cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) appended with modifier -51.

Nephropexy case study: A patient has a surgical injury of the distal ureter, and a ureteroneocystostomy (50780, ureteroneocystostomy; anastomosis of single ureter to bladder) is performed. The ureter has been so damaged that the urologist must remove 2 centimeters. He or she must reanastomize the ureter to reconnect it after removing the damaged part. As part of this procedure, the urologist must move the kidney down and place it in the proper location.

A nephropexy procedure, surgically fixing the kidney to the surrounding fascia to prevent its upward or downward movement, is infrequently performed as a primary procedure. During a kidney procedure such as a pyeloplasty, a nephropexy is also performed and is included in the code. Sometimes a nephropexy must be performed with another procedure, as in this case.

With the loss of ureteral length from the ureteroneocystostomy, the kidney must be mobilized downward to get extra length for an anastomosis. For example, if the ureter is shortened by the repair procedure, as occurs in this case, the kidney must be brought down.

There is no CPT code for a nephropexy, but the extra work of the procedure warrants payment. One way to bill this is 50400 (pyeloplasty [Foley Y-pyeloplasty], plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; simple) with modifier -52 (reduced services) appended to indicate that you are not performing the entire procedure.

The "with or without" verbiage means the code is valued to include nephropexy, whether performed or not. The dollar value of the nephropexy is about 25 percent of the code, estimates Michael Ferragamo, MD, professor of urology at the State University of New York, Stony Brook.

As an alternative, use 53899 (unlisted procedure, urinary system). Find another code with an established value that's similar in intensity to the services, time to perform and risk to the patient such as 50045 (nephrotomy, with exploration). Tell the payer why you equate this code to the nephropexy. Whether you use 50040-52 or 53899, send the operative report and a short explanatory note describing what you did and why.