Urology Coding Alert

All radical nephrectomies should not be coded the same.

Urologists don't always reach the conclusion that they should perform a radical nephrectomy through the same thought processes - it's the differences in how they end up performing 50230 that determine your coding.
 
In all of the following scenarios, the urologist performs a radical nephrectomy, but the factors leading up to the procedure differ and, as a result, so does the correct coding method.
 
 
Scenario 1: Your physician performs a partial nephrectomy, and the pathology report of the frozen section reveals incomplete tumor removal.

If the urologist does not successfully remove an entire tumor through a partial nephrectomy, he or she may decide to perform a radical one to complete the
total nephrectomy.
 
When your physician performs a radical nephrectomy after already performing the partial, you should code both. And you should also expect to be reimbursed for both services because the National Correct Coding Initiative ( NCCI ) does not bundle these two. Analysis: You can bill 50240 (Nephrectomy, partial) and 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy) together, says Doris Kozdron, CPC, coding specialist for Huron Valley Urology Associates in Ypsilanti, Mich.
 
Under these circumstances, remember that the urologist decided to perform a radical nephrectomy based on the pathology report for the partial nephrectomy specimen. You should report 50240 and 50230-51. Modifier -51 (Multiple procedures) tells the carrier that two procedures were performed during a single surgical encounter in the same area of the body and that they should be separately reimbursed. For Medicare patients, you don't need to append modifier -51; Medicare will append it for you.
 
Any code with modifier -51 is subject to Medicare's multiple-procedures payment rule, which reduces the fee for the procedure(s) with modifier -51 by 50 percent, says Jerri Freeman, CPC, CCS-P, CHCC, CHCO, coding specialist in Thomasville, N.C. Consequently, you should "sequence your codes starting with the highest-valued procedure down to the lowest," she says.
 
Scenario 2: The urologist performs a renal exploration, which leads to his decision to perform the radical nephrectomy.

In this case, report only 50230 for the radical nephrectomy. By definition, you should not use the renal exploration code (50010, Renal exploration, not necessitating other specific procedures) under these circumstances.
 
When a physician performs a nephrectomy, renal exploration is an integral part of the procedure and as such should not generate a separate charge.
 
Don't make the mistake of appending modifier -57 (Decision for surgery) to 50010 and trying to report it separately. "Modifier -57 if for E/M codes only," Kozdron says, "and indicates an E/M service that resulted in the initial decision to perform the surgery."

Scenario 3: The urologist performs a renal biopsy, and the pathology report shows a malignant process, so he performs a radical nephrectomy. 
 
If a positive pathology report on a frozen section leads a urologist to perform a radical nephrectomy, you should report 50230 and 50205-59 (Renal biopsy; by surgical exposure of kidney ... Distinct procedural service). Use modifier -59 to unbundle the renal biopsy from the radical nephrectomy. This biopsy now is a separate procedure that led to the decision for a nephrectomy, and modifier -59 will override the NCCI Edit that considers 50205 to be a component procedure of 50230, Kozdron says.
 
Modifier -59, which can be used concurrently with other appropriate modifiers, tells the carrier that you know the procedures are bundled but that you are deliberately reporting the two services separately. Some carriers may require modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) instead of modifier -59 for reimbursement, so be sure to check your local carrier's policy before submitting a claim for 50230 and 50205.
 
If your carrier does require you to use modifier -58 to indicate that the renal biopsy was a staged procedure that led to the radical nephrectomy, make sure you have the necessary documentation to support the use of this modifier (for more on proper documentation strategies, see "Using Documentation Templates? Read This First" below). In these circumstances, modifier -58 will ensure full payment for both the renal biopsy and the radical nephrectomy, and neither service will be subject to Medicare's multiple-procedures payment rule.