Urology Coding Alert

Be careful adding stent insertion codes, too.  

When your urologist performs a pelvic exploration and a ureteral bowel anastomosis and revision, should you separately report the exploration? This sort of surgical scenario trips up many urology coders. 

See how your coding stacks up with the experts’ by testing your hand at coding this case study based on an operative report from Daniel Guckenburg, CPC, surgery coder at Altegra Health, Inc. in Los Angeles. 

Review the Surgical Case

Preoperative diagnoses: 

1. Bladder cancer

2. Left pelvic renal transplant

3. Renal transplant urinary leak

Postoperative diagnosis: 

1. Bladder cancer

2. Left pelvic renal transplant

3. Renal transplant urinary leak

Procedure: 

1. Exploration of pelvis

2. Revision and repair of transplant ureteroileal conduit anastomosis

3. Removal of left double-J stent

4. Placement of 6-French left double-J stent into transplant

Indication for Procedure: 

This patient has a history of bladder cancer treated with a radical cystoprostatectomy. He also had a kidney transplant, and during the prior surgery the ureteral ileal anastomosis was mistakenly performed using the native ureter. The transplant ureter had not been identified due to its marked scarring and adherence deep in the pelvis within the obturator fossa. This became apparent as his pelvic drain output increased representing urine. A nephrostomy tube was placed in the transplant to drain the kidney and help identify the leaking ureter. He was brought to the operating room today for exploration and repair. 

Findings and Procedure: 

There was a leak of the transplant ureter deep in the left side of the pelvis within the obturator fossa. The previous anastomosis of the native ureter to the ileal conduit was taken down with a new anastomosis of the spatulated transplant ureter to the ileal conduit. 

Description of Procedure: 

After informed consent was obtained the patient was taken to the operating room. He was placed in supine position and underwent general anesthesia. His abdomen and genitalia were prepped with Betadine in the usual manner and sterile drapes were applied. We then proceeded to place an Ioban over his abdomen protecting his nephrostomy tube and ileal conduit stoma. We removed the staples, opened up the prior incision, and following removal of a small amount of clot in the pelvis, identified the intact ileal conduit and ureteral anastomosis. We then proceeded to take down the previous anastomosis of the native ureter to the ileal conduit. 

We then focused our attention to the pelvis and following instillation of saline into the nephrostomy tube we were able to identify a small area distally where the ureter had been transected and was lying in the obturator fossa. We placed a stay suture and proceeded to dissect this from the marked fibrotic adherence. We were able to gain sufficient length for anastomosis. We advanced an 8-French open-ended catheter, and a 6-French, open-ended catheter into the renal pelvis, irrigated it and found them to be in good position. We then performed a ureteral to ileal conduit anastomosis with 4-0 PDS, a continuous running 2 layer suture as well as a single suture at the apex for security. Following closure of the back wall a 6-French multi-length double-J stent was placed into the left renal pelvis and with the remainder placed in the ileal conduit. The string was left on the double-J stent for a later attempt to retrieve it. We then proceeded to close the anterior portion of the anastomosis with a similar suture of 4-0 PDS. Watertight closure was noted following irrigation through the prior red Robinson stoma stent and no leakage was identified. We then placed omentum over the anastomosis, irrigated the pelvis with copious amounts of sterile saline with antibiotic solution, placed the remaining omentum once again over the small bowel, and proceeded to close the abdomen with interrupted number 1 Vicryl at the apex and midline along its length, as well as number 1 looped PDS with 2 separate sutures at the superior and inferior portion of the wound, tied separately below the umbilicus. Good closure was noted. We approximated the subcutaneous tissue with Vicryl following irrigation of the wound. The skin was closed with staples.  The patient was then awakened and taken to post-anesthesia room for recovery. 

Coding dilemma: How would you code this procedure? 

Start with the Anastomosis

The first code you should report for this procedure is 50800 (Ureteroenterostomy, direct anastomosis of ureter to intestine). 

“This procedure was the anastomosis of the correct ureter to the ileal conduit,” explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook. 

Remember: Since this was a procedure in which the patient was returned to the operating room to correct a surgical complication that was the result of, and within the global of, an initial surgical procedure, you will need a modifier. Add modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to 50800 to ensure payment. 

Don’t Miss the Add-on Code

Since the urologist used the omentum to cover the anastomosis, you should also report add-on code +49905 (Omental flap, intra-abdominal [List separately in addition to code for primary procedure]). Attach modifier 78 to +49905 just as you did with 50800 to indicate the return to the OR due to complications. 

“Remember that this code as an ‘add-on’ code should not be appended with modifier 51 (Multiple procedures) and you should not reduce its fee,” Ferragamo warns.  

Read more: You can read more about how add-on codes work in the article “3 Tips Improve Your Add-on Code Success” on page 22. 

Skip Separate Pelvic Exploration Coding

When you code for pelvic exploration, you use 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]). In this case, however, you cannot separately report the exploration. Consider the exploration part of 50800.

“Only report the pelvic exploration separately if the urologist performed the exploration and then performed a procedure in another anatomical area unrelated to the exploration,” Ferragamo says. “When the procedure is in the area explored, you should include the exploration in the main procedure’s coding.”

Consider Stent Insertion Included, Too

The final code you might consider reporting is 50605 (Ureterotomy for insertion of indwelling stent, all types) for the open stent insertion. 

Caution: “However, according to both American Urological Association (AUA) policy and the recent National Correct Coding Initiative (CCI), you should not separately report this code,” Ferragamo says. “This CPT code would also be included in the 50800 coding as well.” 

Final coding: You should report the following codes for this case:

• 50800 -78
• +49905 -78

Bonus: Want your complicated operative report featured in Code This!? Send it to Leesa at leesai@codinginstitute.us.