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Correction: Make the Primary vs. Assistant Surgeon Distinction
In Urology Coding Alert Vol. 14, No. 12, there was an incorrect answer printed to reader question "Make the Primary vs. Assistant Surgeon Distinction." We apologize for the misprint. The correct answer is as follows:
Question: I’d appreciate some help with how to bill for the following scenario for a patient with a vena cava thrombus during a kidney removal: Physician A and an assistant physician B, both in the same group, performed an open radical nephrectomy without taking regional lymph nodes. A vascular surgeon was called in to help with the evacuation of vena cava thrombus, which he performed with the assistance of physician A. Because the vascular surgeon is new to this area and is not credentialed, he will not be billing for his portion of the procedure.
Tennessee Subscriber
Answer: You should bill 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy) for physician A and 50230-80 (Assistant surgeon) for physician B. Strictly speaking a radical nephrectomy includes removal of the kidney with Gerota’s fascia and the perinephric fat. Notice that this code also describes nephrectomy with regional lymphadenectomy and/or vena caval thrombectomy. However, the fact that lymph nodes were not taken doesn’t impact the code choice, and you do not report this as "reduced services."
Since physician A performed the radical nephrectomy and participated in the thrombectomy for which the vascular surgeon is not billing, you should list surgeon A as the primary surgeon and surgeon B as the assistant. Recall that an assistant surgeon doesn’t have to be present for the entire procedure or all parts of the procedure. Also note that a thrombectomy can vary from a fairly minor component to an extensive thrombectomy reaching as high as into the right atrium. Whether surgeon A performed or assisted at the thrombectomy, and since the vascular surgeon will not be billing for his part of the procedure, surgeon A should still bill as the primary surgeon using 50230 without modifiers.
Caveat: There are a couple of other factors you should take into consideration. For one thing, you should bill 50230 for Surgeon A as long as the nephrectomy includes removal of Gerota’s fascia and the perinephric fat whether or not a regional node resection and/or caval thrombectomy is performed. Not performing the regional node resection or a caval thrombectomy with the radical nephrectomy does not change the coding. Remember you should never bill this as a simple nephrectomy (e.g., 50220, Nephrectomy, including partial ureterectomy, any open approach including rib resection), which is a much simpler and less complex procedure rarely performed today for kidney carcinoma, cancer of the kidney. A simple nephrectomy removes the kidney at the level of the kidney capsule leaving behind the fatty envelope within Gerota’s fascia which is also left behind.
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