Urology Coding Alert

Heads up: You won’t be able to use a modifier to break the bundles

The National Correct Coding Initiative (NCCI) will help you clean up your ureterectomy coding with edits that take effect April 1. NCCI Edits version 12.1 bundles 50650 into several urology procedure codes, including 50545-50548, to make sure you aren’t double-dipping.

The new edits solidify how coders should and shouldn’t use 50650 (Ureterectomy, with bladder cuff [separate procedure]), coding experts say.

“Code 50650 has a separate-procedure designation on it, which means if it is performed with any other service in that area, it should not be billed out,” says Christopher Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, coding instructor and consultant for Orion Medical Services in Eugene, Ore. “I know people have been trying to do it anyway, and I think that the NCCI edits are just putting a lock on it ... now it’s very clear and in black and white.”

NCCI 12.1 Targets Cystectomies

Thanks to NCCI, after April 1 you’ll be faced with the inability to report a ureterectomy with several other urology procedures, such as ureterocalycostomies and cystectomies. NCCI is placing a “0” modifier on new bundles between 50650 and multiple ureter surgeries (50660, 50740-50940, 50947, and 50948). Version 12.1 also bundles 50650 with cystectomy codes 51550-51597.

“The major impact of the 12.1 NCCI edit on our urologists is the bundling of the open ureterectomy (50650) with the cystectomy codes (51550, 51555, 51570, 51575),” says Trudie Galan, CPC, senior urology coder for Healthcare Information Services in Willowbrook, Ill. The cystectomy codes are the only codes in these new edits that leave urology coders without an option for reporting both a ureterectomy and a cystectomy, Galan adds.

If your urologist performs a cystectomy, it already includes the removal of the lower ureter adjacent to the bladder, and you shouldn’t bill extra for that, says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook.

Therefore, the April NCCI edits will ensure correct coding and eliminate double-dipping since the lower ureterectomy is part of the cystectomy procedure.

‘0’ Means You Can’t Break the Bundle

When your urologist performs a nephrectomy and a ureterectomy, you’ll have to be careful which codes you use to report his work. After April 1, you’ll have to take note of new and revised bundles between 50650 and certain nephrectomy procedure codes.

NCCI version 12.1 is changing the modifier indicator on several 50650 bundles from “1” to “0.” This means that you won’t ever be able to use a modifier to separately report 50650 with the following codes under any circumstances:

• 50220--Nephrectomy, including partial ureterectomy, any open approach including rib resection

• 50230--Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy

• 50234--Nephrectomy with total ureterectomy and bladder cuff; through same incision

• 50236--…through separate incision

• 50546--Laparoscopy, surgical; nephrectomy, including partial ureterectomy

• 50548--Laparoscopy, surgical; nephrectomy with total ureterectomy.

Example: Your urologist performs a laparoscopic nephrectomy and total ureterectomy. To ensure that he removed the entire ureter and the cuff of the bladder, he performs an open lower ureterectomy with bladder cuff.

Previously, you might have reported this procedure with codes 50548 and 50650, appending modifier 59 (Distinct procedural service) to the open procedure code to indicate that it was separate. You can no longer use both codes. Instead, you should report just 50548 for the nephrectomy and total ureterectomy.

“Unfortunately the edit between 50650 and 50548 may compromise the surgical procedure, because the urologist will either do both procedures and not get paid for one or may choose not to perform the open procedure,” Ferragamo says.

Tip: Although NCCI edits with a “0” modifier indicator prohibit you from appending modifiers, such as 59, to break the bundle between the codes, you can still use modifier 22 (Unusual procedural services) if the circumstance warrants. If your urologist encounters unusual circumstances during surgery, be sure to attach modifier 22 so he receives the additional allowance for the more complicated surgery.

Avoid 50650 With Laparoscopic Nephrectomies

You also won’t be able to report a ureterectomy with bladder cuff with other types of nephrectomies. NCCI is adding new edits bundling 50650 into the following procedures:

• 50225--Nephrectomy, including partial ureterectomy, any open approach including rib resection; complicated because of previous surgery on same kidney

• 50545--Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota’s fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy)

• 50547--Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor.
 
Each of these new bundles also has a “0” modifier indicator, so you can’t use a modifier to break the bundle.

Bottom line: If your urologist does a nephrectomy, whether it’s radical or simple, and you also bill for a ureterectomy, you’re not coding properly. NCCI is adding these edits to keep coders from billing for a procedure that’s already included in the nephrectomy, Ferragamo says. If the surgeon does a nephrectomy and total ureterectomy, you should be using only 50234, 50236, or 50548, he adds.