Urology Coding Alert

3 answers can boost your reimbursement by 30 percent

Can't find a code for a hand-assisted laparoscopic nephrectomy? You're not alone. Many coders are still confused about how best to get reimbursed for this relatively new procedure, but this expert advice will set your claims on the right track.

In hand-assisted laparoscopic (HAL) surgery, the urologist makes small incisions for insertion of scopes and instruments, and an extra incision for his hand to assist with the surgery. HAL surgery can significantly reduce operative time and the risk of complications during complex procedures, and can lead to a shorter recovery time. While that's good news for the patient, you might not want to mention that in any appeal letters you write explaining the procedure.

"Insurance companies tend to equate quicker recoveries with simpler procedures and may pay you less," says Alice Kater, CPC, coder for Urology Associates of South Bend, Ind. It isn't a simpler procedure, though: "It takes longer, it's more complex, and you need more training."

1. How should I account for the additional work involved in HAL when submitting my claim?

If a urologist performs a radical nephrectomy using HAL surgery, for example, you would report 50545-22 (Laparoscopy, surgical; radical nephrectomy; unusual procedural services) to account for the complexity of the procedure -- but only if you can justify and document that the procedure is truly greater than usually required.

For example, if the urologist requires the hand assistance to complete the surgery because of extensive fibrosis or excessive vasculature, and this extra work prolongs the surgical time, you can append -22 as long as you document the facts. You would have to send in a paper, rather than an electronic, claim.

A paper claim will trigger an automatic review by the insurer, so send the operative note, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stonybrook. You should also send a short letter explaining the procedure in layman's terms, since the person reviewing your claim will likely not be a medical professional.

"Probably the most important thing," Ferragamo says, "is to put down the extra time it took you to do this procedure as compared to a laparoscopic radical nephrectomy. Then indicate how much more you want the carrier to pay you." Used appropriately, he says, modifier -22 can add 25 to 30 percent to your HAL nephrectomy reimbursement.

2. Will an insurer pay for HAL if I report both an open procedure code with modifier -52 and a laparoscopy code?

Even though HAL requires special skill, Ferragamo advises against billing for both a laparoscopy procedure and an open procedure code, appending -52 (Reduced services) to the open code. "You can only use the code for what you're doing," he says. "You're not doing an open procedure, so you shouldn't code for it." Choosing a code strictly for its ability to pay more rather than to accurately describe the procedure leads to fraud.

Some private carriers, however, will require you to code two procedures. For example, for a hand-assisted laparoscopic radical nephrectomy, you would need to code 50545-59 (Laparoscopy, surgical; radical nephrectomy; distinct procedural service) and 50230-52 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy; reduced services). You need to append -59 to unbundle 50545 from 50230, Ferragamo says. And you should append -52 to show that the urologist did not perform the total open procedure. He notes that Medicare has on occasion also reimbursed for these codes.

3. Will a carrier reimburse an unlisted-procedure code used to represent HAL?

In the above example, there's a case to be made for using 50549 (Unlisted laparoscopy procedure, renal). If no existing code accurately describes the service provided, CPT guidelines instruct you to use the appropriate unlisted-procedure code. Some additional unlisted-procedure codes you might use are 50949 (Unlisted laparoscopy procedure, ureter) and 60659 (Unlisted laparoscopy procedure, endocrine system). Include a letter of explanation from the physician stating the reason and rationale for using that particular code.

Best Bet: Straight Laparoscopy Code. Fortunately, there is a code that accurately and specifically describes a HAL procedure: the straight laparoscopy code. Ferragamo thinks this is the most appropriate method. "I and many other urologists feel that the hand in the wound replaces a portal and a portal instrument," he says. "The hand acts as a portal instrument. Because of this, I feel that 50545 alone is the proper code to use in this situation."