Urology Coding Alert

Hint: Report 49323 for laparoscopic drainage of a peritoneal lymphocele.

When your urologist performs drainage procedures of the flank or other areas, you must check the medical documentation for numerous details including the type of approach and whether they had to drain an abscess or other pathology such as a lymphocele.

Follow four handy tips to always submit clean flank drainage claims in your practice.

Tip 1: Use These Codes for Perirenal, Renal Abscess Drainage

You will choose different codes depending upon whether your urologist performed open or percutaneous drainage of the perirenal or renal abscess.

Open drainage: If the patient has a complicated (multiloculated or multiple) perirenal or renal abscess or abscesses, your urologist will probably choose an open method of drainage. You should report code 50020 (Drainage of perirenal or renal abscess, open) for open drainage.

Percutaneous drainage: On the other hand, if your urologist performs percutaneous image-guided drainage of a perirenal or renal abscess via a catheter, you should report code 49405 (Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous).

Remember: You should never report code 49405 in conjunction with radiological guidance for percutaneous code 75989, ultrasonic guidance for needle placement code 76942, fluoroscopic guidance for needle placement codes +77002 and +77003, computed tomography (CT) guidance code 77012, and Magnetic resonance imaging (MRI) guidance code 77021, according to CPT^®.

Tip 2: Rely on Specific Options for Peritoneal, Retroperitoneal Drainage

If your urologist performs peritoneal drainage, you also have specific code choices.

Laparoscopic drainage: If your urologist performs laparoscopic peritoneal drainage for a lymphocele, you should report code 49323 (Laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity).

Don’t miss: You won’t find any code for laparoscopic drainage of a peritoneal abscess because your urologist will rarely perform this procedure, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook New York.

Open drainage: You should report code 49062 (Drainage of extraperitoneal lymphocele to peritoneal cavity, open) if your urologist performs open drainage of a lymphocele.

On the other hand, you should report code 49060 (Drainage of retroperitoneal abscess, open) if your urologist performs open drainage of a retroperitoneal abscess.

Finally, you should report code 49020 (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open) if your urologist performs open drainage of a peritoneal abscess.

Percutaneous drainage: You should report 49406 (Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous) if your urologist performs percutaneous drainage via a catheter for a peritoneal or retroperitoneal lymphocele or abscess.

Lymphocele defined: A lymphocele is a postsurgical complication that develops when the lymphatic system gets damaged during procedures like a renal transplantation or retroperitoneal surgery. This damage causes the lymph fluid to drain out from the lymphatic channels and build up in a nearby cavity.

Tip 3: Urologist Performs Two Procedures at Same Time? Do This

If the patient has an infection in the psoas muscle, which starts as an infection in and around the kidney, your urologist will need to drain both the psoas and the renal abscesses.

For the psoas drainage, you should report (49406 for a percutaneous approach or 49060 for an open approach) and for the renal abscess drainage, you should report (49405 for a percutaneous approach and 50020 for an open approach).

Don’t miss: Once you determine which approaches your urologist used, you should either append the appropriate National Correct Coding Initiative modifier (NCCI) (such as, modifier 59) to break the Procedure-to-Procedure (PTP) edit or modifier 51 (Multiple procedures) if the procedures are not bundled.

Example: Your urologist performs a percutaneous renal abscess drainage (49405) and a percutaneous psoas abscess drainage (49406). Code 49406 is a Column 2 code for 49405, meaning those two procedures are bundled. But you can append the appropriate NCCI modifier such as modifier 59 if the medical documentation supports that your urologist performed the drainage on separate sites.

On the other hand, if your urologist performs both drainage procedures via open access, you should report 50020 on the first line of your claim form and 49060-51 on the second line of your claim form.

Note: If, however, the urologist decides to perform both drainage procedures via an open access, modifier 59 is not needed as there is no bundling issue. Therefore, report 50020 on the first line of the claim form, and 49060-51 on the second line.

Tip 4: Remember Modifiers in Certain Situations

You should make sure you know how to append modifiers correctly to flank drainage procedures, as well.

For example, during a new patient examination for flank pain and fever, your urologist discovers that the patient has a renal abscess. Your urologist spends 35 minutes with the patient and performs a medically appropriate history and exam. Your urologist then decides to perform an open drainage of the renal abscess the next day.

You should report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.) for the evaluation and management (E/M) visit with modifier 57 (Decision for surgery) appended for day one. The next day, you should report 50020 (Drainage of perirenal or renal abscess, open) for the renal abscess drainage.

Modifier 57 explained: You should append modifier 57 to an E/M service that occurs on the same day, or on the day before, a major surgical procedure, and which results in the physician’s decision to perform the surgery. Guidelines from the Centers for Medicare & Medicaid Services (CMS) identify a major surgical procedure as any procedure with a 90-day global period. When you look up the global period for 50020, you will see that it is 90 days.

Note that the global period for a major surgical procedure begins one day prior to the procedure itself.

Direct from the source: The Medicare Claims Processing Manual, Chapter 12, Section 30.6.6.C, instructs carriers to “pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT^® modifier 57 to indicate that the service resulted in the decision to perform the procedure.”

Don’t look for a loophole: Scheduling pre-op services two or more days before surgery will not necessarily make the services payable without a modifier. Insurers may consider such services to be screening exams unless there is some specific indication, such as hypertension or diabetes. The documentation for these visits must substantiate medical necessity and not just a routine requirement of the physician or the hospital.

To properly append modifier 57, remember that the E/M service must be related to the procedure that follows; and the same physician (or tax ID) must provide the E/M service and the surgical procedure.