Urology Coding Alert

No two surgeries are exactly alike, especially when you're referring to nephrectomies -- therefore, you won't always code the surgery exactly the same way. But if you can learn the basics, based on three common scenarios, you'll be able to accurately code any nephrectomy operative session with ease.

Scenario 1: When faced with a small renal (kidney) cell carcinoma (cancer), a urologist often performs a partial nephrectomy, removing only the tumor and a small portion of surrounding normal kidney tissue. The pathology report of the frozen section, however, may occasionally reveal incomplete tumor removal, and the surgeon will then correctly perform a radical nephrectomy (complete removal of the kidney) as definitive therapy.

You can report both the partial nephrectomy and the radical nephrectomy under these clinical circumstances. You would report 50240 (Nephrectomy, partial) and 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy), says Christy Shanley, CPC, billing manager for the University of California, Irvine department of urology. Append modifier 51 (Multiple procedures) to 50230 to show the payer that your urologist performed the two procedures during one operative session via one incision. Report 50240 first because payers assign the highest relative value units (RVUs) to that code.

Pointer: The Correct Coding Initiative (CCI) does not bundle 50240 and 50230 together so you can expect separate reimbursement for each procedure. The positive margin (for residual tumor) did lead the urologist to perform the radical second procedure, which supports separately reporting the two procedures.

Consider Exploration as Part of Kidney Removal Scenario 2: The urologist performs a renal exploration, which leads to his decision to perform the radical nephrectomy.

In this case, you may be tempted to report both the radical nephrectomy -- 50230 for an open procedure or 50545 (Laparoscopy, surgical; radical nephrectomy [includes removal of Gerota's fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy]) for a laparoscopic approach -- and the renal exploration code (50010, Renal exploration, not necessitating other specific procedures).

Take a look at the code descriptor for 50010, however. "The renal exploration code clearly states that 'the physician may not perform any other procedures at this time,'" says Jonathan Rubenstein, MD, director of coding and physician compliance for Chesapeake Urology Associates in Baltimore. "Therefore, the correct code to use is the completed code only -- 50230 for open radical nephrectomy, and 50545 for a laparoscopic radical nephrectomy.

Pitfall: Even though the renal exploration led to the urologist's decision to perform surgery, don't make the  mistake of appending modifier 57 (Decision for surgery) to 50010 and trying to report it separately. You can use modifier 57 only on E/M service codes, not on procedure codes, Rubenstein cautions.

Scenario 3: Your urologist performs a renal biopsy, and the pathology report shows a malignant process, so he then performs a radical nephrectomy.In this case, you should report both the nephrectomy and the biopsy since the positive pathology report on the frozen section led your urologist to perform a radical nephrectomy. First, report the radical nephrectomy code using either 50230 or 50545, based on whether the urologist used an open or laparoscopic approach. Then, report the biopsy using 50205 (Renal biopsy) or 49321 (Laparoscopy, surgical; with biopsy [single or multiple]), also based on the surgical approach, Rubenstein says.

Append modifier 59 (Distinct procedural service) to the biopsy code (50205) to indicate to the payer that you are breaking the CCI bundle between 50230 and 50205 because your urologist performed distinct procedures during the same operative session. Alternately, you can consider appending modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to 50205 to indicate that the positive biopsy prompted the urologist to proceed with the radical nephrectomy.

Lap approach: When your urologist performs the biopsy and nephrectomy laparoscopically, report 50545 and 49321-51. You do not need modifier 59 because CCI does not bundle these two codes.

Additionally: If your urologist performs an intraoperative renal ultrasound for guidance in the localization and extent of the tumor, you should also report 76998 (Ultrasound guidance,  ntraoperative). Append modifier 26 (Professional component) to 76998 to show that you are coding only for your physician's services, the interpretation of the study.

Regardless of the scenario that leads to a radical nephrectomy, when the physician performs a radical nephrectomy but does not remove the adrenal gland, you should still report 50230 or 50545.

"I use 50230 and 50545 for radical nephrectomy and laparoscopic radical nephrectomy respectively, irrespective on whether the adrenal gland is removed, as it generally takes me the same amount of time and effort, as it does not change my surgical technique," Rubenstein confirms.

Caution: When the urologist leaves the adrenal gland, don't append modifier 52 (Reduced services) to indicate a reduced operative procedure, Shanley says.

You also should not report a simple nephrectomy code (50220, Nephrectomy, including partial ureterectomy, any open approach including rib resection, or 50546, Laparoscopy, surgical; nephrectomy, including partial ureterectomy) instead of a radical nephrectomy code.