Urology Coding Alert

Rely on your knowledge of anatomy so nothing gets lost in translation.

If detailed urology operative reports have you scratching your head, you’re not alone. Coding nuanced operative reports can pose challenges for coders of all experience levels if they are not well-equipped to interpret, and properly translate, all aspects of a given surgical report.

That’s why experts say the best approach is to break down the report into smaller, more manageable pieces — with the end goal of translating the report from surgeon-speak to something more digestible to the average coder.

Try your hand at this example to take your surgical coding to the next level.

Know What Services Qualify as Included Prerequisites

Part 1: Care was taken to prep in the existing left nephrostomy tube to our sterile field. We then began by accessing the left percutaneous nephrostomy tube and performed an antegrade pyelogram. We advanced a sensor wire into the left kidney. The nephrostomy tube was removed. A Kumpe catheter was utilized to direct the wire down the ureter and into the bladder. Over the wire, a dual lumen was used to advance a second wire into the bladder. One wire was secured as a safety wire and the other was used as our working wire.

Translation: The provider removes an existing nephrostomy tube and proceeds to prepare the site for insertion of a cystoscope. Preparation involves insertion of a catheter to direct a sensor wire (guidewire) through the ureter and into the bladder. The provider inserts a safety guidewire in order to provide access to the collecting system or ureter in the in case of complications. However, some providers may opt to perform this procedure without the use of a safety guidewire. You should consider this portion of the surgery inclusive to the next portion of the procedure involving a renal endoscopy.

See How Established Access Points Change Coding Fundamentals

Part 2: We dilated the nephrostomy tract using rigid dilators starting at 18F up to 24F. We advanced the sheath over this under fluoroscopic guidance. A flexible cystoscope was then used to perform systematic nephroscopy of the kidney. No stones were noted in the upper tract.

Translation: The surgeon performs a nephrostomy tract dilation in order to advance the catheter sheath under fluoroscopic guidance. This sheath will be used as an endoscopic access point for the insertion of the cystoscope and ureteroscope to follow in Part 3. The surgeon then inserts a flexible cystoscope via the access sheath to examine the kidney and surrounding renal pelvis.

Code a nephroscopy, also known as a kidney endoscopy (per the CPT^® index), using 50551 (Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service). Within the CPT^® index, Endoscopy ? kidney ? via stoma presents you with a selection of numerous renal endoscopy codes. However, since no stones were identified, report the code indicating a diagnostic service, 50551.

Note: Despite the fact that the code description indicates that it’s exclusive of radiologic service, you should not report 76000 (Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time) separately. National Correct Coding Initiative (NCCI) edits reveal a modifier “1” indicator on the column 2 code (76000) when paired with 50551. “CMS/NCCI guidelines instruct you to include 76000 as an integral component of all endoscopic procedures when performed,” explains Becky Boone, CPC, CPMA, CEMC, CUC, Senior Urology Surgery Coder at The Coding Network, LLC. “Therefore, you shall not report 76000 separately with an endoscopic procedure,” Boone advises.

Don’t Mistake No NCCI Bundling Edits For a Green Light

Part 3: A flexible ureteroscope was inserted via the access sheath into the ureter, which was followed until we identified two stones. One was removed with a Zero Tip™ basket. The second was too large, so a holmium laser fiber was obtained. The 200-micron holmium laser fiber was introduced and used to fragment the stoneinto multiple pieces. We then changed back to the flexible cystoscope and repeated evaluation of the upper tract. No stones were seen. An antegrade pyelogram was obtained through the scope to ensure all areas were evaluated, again with no stone seen.

Translation: The surgeon retracts the cystoscope and inserts a ureteroscope for visualization of the ureter. According to manufacturer Boston Scientific, the Zero Tip™ Nitinol Stone Retrieval Basket is a “versatile tipless nitinol basket designed for use in the kidney and ureter.” The basket can be used for smaller stone fragments; however, the surgeon has to resort to laser vaporization for the larger stone. Following fragmentation of the stone using a holmium laser, the surgeon removes the ureteroscope and reinserts the cystoscope for evaluation of the upper urinary tract. The surgeon then injects a contrast dye into the cystoscope to illuminate the urinary tract. This injection, coupled with subsequent X-ray imaging that ensures all urinary calculi have been accounted for, is known as an anterograde pyelogram.

Report the entirety of this portion of the procedure with 50961 (Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus). Utilizing the CPT^® index using the same method as the nephroscopy, Endoscopy ? Ureter ? via Stoma leads you to 50961 since the provider found and removed ureteral calculus. The code description includes ureteropyleography, meaning you should not report the anterograde pyelogram separately.

Coder’s note: “Despite no National Correct Coding Initiative (NCCI) bundling edits, you should consider 50430 (Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; new access) as an included component of 50961 and not separately billable,” advises Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook.