Urology Coding Alert

For an open approach, you should report code 60540.

When you code for an adrenalectomy, you need to look for numerous details in the medical documentation. For example, you need to know whether the urologist used an open or laparoscopic approach. You should also know whether the urologist also removed a retroperitoneal mass along with the adrenalectomy and if the adrenalectomy was associated with another surgical procedure such as a radical nephrectomy.

Read on to learn more.

Step 1: Pinpoint Surgical Approach

When you report an adrenalectomy, you should first check your urologist’s medical documentation and verify the type of approach he used.

Laparoscopic approach: For a laparoscopic approach, you should report code 60650 (Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal).

Open approach: For an open approach, you should report code 60540 (Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure)).

Don’t miss: Many urologists opt for a laparoscopic approach over an open surgical approach for an adrenalectomy because open surgery can be difficult and require a large incision since the glands are located deep in the retroperitoneum.

Step 2: Check for Retroperitoneal Mass Excision

In some cases, your urologist may excise a retroperitoneal mass in addition to the adrenalectomy.

Open approach: If your urologist excises the mass via an open approach, along with the adrenalectomy, you should report 60545 (Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal [separate procedure]; with excision of adjacent retroperitoneal tumor).

Laparoscopic approach: If your urologist uses a laparoscopic approach to excise a retroperitoneal mass along with the adrenalectomy, you have two options. First, you can append modifier 22 (Increased procedural service) to 60650 to represent the extra work your urologist performed with excising the retroperitoneal mass. Your urologist will need to clearly document the extra work and time he spent on the removal.

For the second option, you can consider reporting an unlisted code along with 60650. You can look to either 49329 (Unlisted laparoscopy procedure, abdomen, peritoneum and omentum) or 60659 (Unlisted laparoscopy procedure, endocrine system). Make sure your urologist provides detailed documentation explaining that he performed extra dissection and surgical work warranting the unlisted code.

Step 3: Identify Bundled Procedures

Occasionally, when your urologist performs an adrenalectomy, he also does work that includes the adrenal gland and another organ, such as the kidneys. You should not code these services separately.

For example, all radical nephrectomies, whether open or laparoscopic, include an adrenalectomy.

You should not separately report an adrenalectomy with a procedure like 50545 (Laparoscopy, surgical; radical nephrectomy [includes removal of Gerota’s fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy]) because the code descriptor includes the adrenal gland removal.

Also, Medicare’s National Correct Coding Initiative (NCCI) includes an adrenalectomy as part of a simple nephrectomy, which doesn’t include removal of Gerota’s fascia or lymphadenectomy, bundling the open and laparoscopic adrenalectomy codes with all nephrectomy codes.