Urology Coding Alert

Don't miss out on additional procedures and services for which you deserve reimbursement.

Laparoscopic procedures are becoming more commonplace in urology practices and pyeloplasty procedures are no exception. Don't let this new surgical technique throw off your coding and cost your practice money.

"I understand that this particular procedure [laparoscopic pyeloplasty] has really replaced the open pyeloplasty," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. "Understanding how to code the various clinical scenarios associated with a pyeloplasty repair is of utmost importance in remaining compliant and to receive correct reimbursements."

With this in mind take a look at three common clinical scenarios in coding pyeloplasty procedures to ensure you're up to speed.

Bonus: There are a number of codes you can legitimately report in addition to a laparoscopic repair of a ureteropelvic junction (UPJ) obstruction.

Watch for Bundles Involving Laparoscopic Pyeloplasty

Scenario 1: Your urologist performs a laparoscopic pyeloplasty for a UPJ obstruction. He also performs a preoperative cystoscopic examination and retrograde pyelogram and places a double J stent.

First: In this case bill first for the highest paying service, the laparoscopic pyeloplasty (50544, Laparoscopy ,surgical, pyeloplasty) as your primary procedure code. The appropriate diagnosis code is 753.21 (Congenital obstruction of ureteropelvic junction).

Next, bill for the insertion of the JJ stent using 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]). Append modifier 51 (Multiple procedures) if your payer requires that modifier for multiple procedures performed during the same session and assign ICD-9 codes 591 (Hydronephrosis) and V07.8 (Other specified prophylactic or treatment measure). Reporting V07.8 is "using a combination of ICD-9 codes to explain the placement of the stent prophylactically to prevent hydronephrosis," Ferragamo says.

Pitfall: You should not bill the cystoscopy (52000) or retrograde pyelogram (52005 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) because these procedures are included in the 52332 coding, per the Correct Coding Initiative (CCI). You cannot unbundle them.

However, you can bill for a formal reading of the retrograde pyelogram if performed, using 74420 (Urography, retrograde, with or without KUB). Append modifier 26 (Professional component) to indicate your physician only performed the professional side of that service -- the film interpretation -- and that he does not own the hospital-based equipment nor pays for the technician or contrast materials used. Again, use diagnosis code 753.21.

Add All Renal Procedure Codes When Performed

Scenario 2: Your urologist performs a renal endoscopy through a previously placed established nephrostomy site, removes a small renal pelvic stone, replaces the nephrostomy tube, and performs a nephrostogram revealing a ureteropelvic junction obstruction. He then decides to perform a laparoscopic pyeloplasty for a UPJ obstruction.

"This is an unusual approach and a more complicated scenario than the first procedure," Ferragamo explains.

Start the same way: As with the first scenario, you'll first report 50544 for the laparoscopic pyeloplasty because that code again carries the highest relative value units (RVUs). Again, you'll use 753.21 as the diagnosis code.

Next, you should report 50561 (Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, installation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus) for the renal endoscopy with stone removal. Append modifier 51, if necessary. "This code also includes the instillation of contrast material for the nephrostogram," Ferragamo says. Your diagnosis code will be 592.0 (Calculus of kidney).

Additionally: You can also bill the removal and replacement of the nephrostomy tube using 50398 (Change of nephrostomy or pyelostomy tube). Attach 51, if your payer requires that modifier. Assign diagnosis code 591 to 50398.

Finally, if your urologist interprets the nephrostogram and documents his radiological findings within the operative report under a separate heading, then report the nephrostogram interpretation with 74425 (Urography, antegrade [pyelostogram, nephrostogram, loopogram], radiological supervision and interpretation). Attach modifier 26 since the urologist performed only the reading and interpretation portion of the nephrostogram. The diagnosis code associated with the nephrostogram should be 753.21.

No edits: "These codes are not bundled and are billable under this scenario," Ferragamo says.

Tackle Vessel Excision With 50544

Your urologist performs a laparoscopic pyeloplasty for a patient with a UPJ obstruction. He also performs an excision of crossing venous vessels. Before the procedure he also performs a preoperative cystoscopic examination and retrograde pyelogram and places a double J stent.

Stick with 50544: Just as in the last two scenarios, you'll report the laparoscopic pyeloplasty as the primary procedure using 50544 with diagnosis code 753.21.

Then, report 55550 (Laparoscopy, surgical, with ligation of spermatic veins for varicocele) for the excision of crossing venous vessels. Attach 51 if necessary. You'll assign 747.62 (Renal vessel anomaly) for this diagnosis.

As with the first scenario, you would bill for the insertion of the double J stent using 52332-51. Use ICD-9 codes 591 and V07.8 to explain the prophylactic stent placement. Report the reading and interpretation of the retrograde pyelogram with 74420-26. Use diagnosis code 753.21.