Urology Coding Alert

Use these real-world examples as your guide.

A multitude of questions need answering before you finalize codes for an adrenalectomy: Did the surgeon use an open or laparoscopic approach? Was the procedure partial or complete? Were other services performed during the same encounter? Our experts are here to keep you – and your physician's reimbursement – on the right track.

Start with the Surgical Approach

New technologies and techniques mean that more surgeons are opting for a laparoscopic approach when they perform an adrenalectomy. Plus, while adrenal glands are small, open surgery can be difficult and require a large incision since the glands are located deep in the retroperitoneum.

Caution: Don't assume, however, that your physician will automatically use a laparoscopic approach. Verify by double checking the operative report and then choose the correct primary code:

• 60650 – Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal
• 60540 – Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure).

Tip: CPT^®  codes typically distinguish tissue removal procedures by surgical approach such as open, laparoscopic, core needle, etc. An adrenalectomy is tissue removal, and that is why you'll find the 60650/60540 distinction for adrenal glands.

Surprise: But unlike surgeries involving other organs, CPT^® doesn't differentiate between resection and biopsy for adrenal tissue. The descriptors for both 60650 and 60540 describe an "adrenalectomy, partial or complete" OR "exploration of adrenal gland with or without biopsy." That means you'll choose one of these codes whether the surgeon simply "explores" the adrenal gland or removes the entire organ.

Check Whether Other Tissue Removals Change the Coding

It's not unusual to find notes in your surgeon's operative report about additional tissue(s) addressed during the encounter – and these can potentially change how you report the case.

Example  1: If the surgeon finds and excises a retroperitoneal mass associated with the adrenal gland, you should alter your coding and collect appropriate pay. For an open procedure, that means changing your code selection from 60540 to 60545 (Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal [separate procedure]; with excision of adjacent retroperitoneal tumor). For a laparoscopic procedure, you might consider adding modifier 22 (Increased procedural service) to 60650, or reporting an unlisted code such as 60659 (Unlisted laparoscopy procedure, endocrine system) in addition to 60650 to describe the extra dissection and surgical work to remove the retroperitoneal mass.

Example 2: If your surgeon performs 60650 and 38570 (Laparoscopy, surgical; with retroperitoneal lymph node sampling [biopsy], single or multiple), expect full reimbursement for the procedure with the highest relative value units (RVUs). That is 60650 in this example, which pays $1,237.70 (according to the 2018 unadjusted Medicare Physician Fee Schedule [MPFS] national facility amount, based on conversion factor $35.99). Additionally, most insurers will also pay 50 percent of the lesser service, or $263.81 (half of $527.61, the 2018 unadjusted MPFS national facility amount for 38570).

Example  3:  If the surgeon removes a lymph node or nodes in addition to the adrenal gland, you might be able to separately code the procedure using a code such as 38564 (Limited lymphadenectomy for staging [separate procedure]; retroperitoneal [aortic and/or splenic]) or 38570, depending on the approach.

Missing this extra work, such as not reporting 38570, a lymph node dissection, in addition to a 60650 laparoscopic adrenalectomy, could cost your practice. Although your payer will impose a multiple-procedure payment reduction on the secondary scope procedure, you would not want to miss the additional pay you really deserve.

Don't  miss  bilateral: If the surgeon removes or biopsies both adrenal glands, you will need to append modifier 50 (Bilateral procedure) to the procedure code. Medicare and many other insurers will pay 150 percent of the fee-schedule amount for bilateral procedures. That means getting paid an unadjusted Medicare fee of $1,656.80 by using modifier 50, instead of $1104.53 for a bilateral open adrenalectomy (60540) billed without the modifier.

"Some payers may not recognize modifier 50, and may want you to submit the procedure code twice using modifiers LT (Left side [used to identify procedures performed on the left side of the body]) and RT (Right side [used to identify procedures performed on the right side of the body])," says Terri Brame  Joy,  MBA,  CPC,  COC,  CGSC,  CPC-I, director of operations with Encounter Telehealth in Omaha, Nebr.

Be Savvy to Bundled Services

Sometimes you'll find a surgical report that includes an adrenal gland and other tissues that you can't code separately, such as the kidneys.

Here's why: "An adrenalectomy is included in all radical nephrectomies, whether performed open or laparoscopically," says Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York in Stony Brook.

You should never separately report an adrenalectomy with a procedure such as 50545 (Laparoscopy, surgical; radical nephrectomy [includes removal of Gerota's fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy]), because the code definition clearly includes the adrenal gland removal.

But Medicare's National Correct Coding Initiative (CCI) goes further and includes an adrenalectomy as part of a simple nephrectomy (which doesn't include node dissection, Gerota's fascia removal, or lymphadenectomy), bundling the open and laparoscopic adrenalectomy codes with all nephrectomy codes.

Separate  procedure:  This CCI bundling conforms to CPT^® rules for "separate procedure" codes such as 60540 and 60545. According to CPT^® instruction, "Codes designated as 'separate procedures' may not be additionally reported when the procedure/service is performed as an integral component of another procedure/service."

Test Your Real-world Knowledge

Now that you've re-familiarized yourself with the basics of adrenalectomy coding, decide how you would handle the following three scenarios. Then turn to page XX for the answers.

Question 1: According to CPT^®, you should report 60545 when the surgeon (via an open approach) excises a retroperitoneal mass in addition to the adrenalectomy. If the urologist uses a laparoscopic approach, does the work of 60650 cover both the excision of the retroperitoneal mass and the adrenalectomy?

Question 2: The surgeon performs a left adrenalectomy and a partial left upper pole nephrectomy on a patient whose adrenal cancer was invading the upper pole of his left kidney. Adrenalectomy is bundled into radical nephrectomy. How do you report this pathological scenario in conjunction with a partial nephrectomy?

Question 3: The surgeon completes a laparoscopic adrenalectomy and resects peritoneal and omental tumor implants during the same session. What codes do you include on the claim?