Urology Coding Alert

The term “nephrectomy” refers to kidney removal. A nephrectomy might be partial or complete (a simple or radical nephrectomy), and might be completed using open, laparoscopic, or robotic-assisted laparoscopic techniques. It might also arise unexpectedly, when the urologist takes a patient into surgery to perform one procedure but shifts to (or also performs) a nephrectomy because of the clinical circumstances.

Whatever situation you might find yourself reporting, read on for a rundown of the various aspects involved with nephrectomy coding.

Begin by Understanding Types and Causes

Option 1: During a simple complete nephrectomy, the urologist removes the kidney with the line of dissection at the renal capsule, leaving behind the enveloping fascia (Gerota’s fascia), the perinephric fat, and the adrenal gland. A simple nephrectomy is usually performed for benign conditions of the kidney such as a chronic infection and/or a non-functioning kidney, says Michael A. Ferragamo MD, FACS, assistant clinical professor of urology with the State University of New York, University Hospital and Medical School at Stony Brook.

Option 2: During a radical nephrectomy, the urologist removes the entire kidney, Gerota’s fascia, the fatty tissues surrounding the kidney, and a portion of the ureter. He might also remove the adrenal gland atop the kidney if a tumor is close to or involves the adrenal gland. A radical nephrectomy is usually performed for a malignant disease of the kidney such as a renal carcinoma (cancer).

Option 3: During a partial nephrectomy, the surgeon removes diseased kidney tissue leaving normal healthy tissue in place. The diseased tissue often is a tumor, and the decision of how much kidney to remove depends on several factors:

• Whether more than one tumor is present
• Whether the tumor is confined to the kidney
• How much of the kidney is affected by the pathology (tumor)
• Whether the cancer affects nearby tissue, and
• How well the other kidney functions.

The most common kidney cancer in adults, renal cell carcinoma, begins in the cells that line the small tubes within your kidneys. Children are more likely to develop a type of kidney cancer called Wilms’ tumor, probably caused by the poor development of kidney cells.

Be aware: Not all nephrectomies occur because of tumors, however. A partial or simple nephrectomy might be necessary because of traumatic injury to a kidney or a disease which has led to extensive kidney damage, scarring, or non-functioning of a kidney.

Know What Each Technique Represents

Your surgeon has several options for performing a nephrectomy, based on the individual patient’s situation (including how much of the kidney will be removed). These options include:

• Open surgery: In an open nephrectomy, the surgeon makes an incision in the flank, along the patient’s side, usually between the lower ribs, or an incision in the abdomen. When using a flank incision, the surgeon may need to remove a lower rib to gain better access to the kidney.
• Laparoscopic surgery: In this minimally invasive procedure, the surgeon makes a few small incisions in the abdomen in order to insert wand-like devices equipped with video cameras and small surgical tools. The surgeon makes a somewhat larger opening if the entire kidney needs to be removed.
• Robotic-assisted laparoscopic surgery: In this variation of laparoscopic surgery, the urologist uses robotic tools that provide better imaging of the surgical site, and enables precise removal of diseased tissue.

The surgeon decides on the most appropriate technique based on imaging test results, which may include:

• Ultrasound, an image of soft tissues produced with the use of sound waves
• Computerized tomography (CT), a specialized X-ray technology that produces images of thin cross-sectional views of soft tissues of the abdomen and the kidneys.
• Magnetic resonance imaging (MRI), which uses a magnetic field and radio waves to produce cross-sectional views or 3-D images of the abdomen and kidneys.

Familiarize Yourself With the Various Nephrectomy Codes

CPT^® 2017 has numerous coding options for nephrectomy, based on the extent of the procedure and the surgeon’s technique. Your choices for an open procedure are:

• 50220 – Nephrectomy, including partial ureterectomy, any open approach including rib resection
• 50225 – Nephrectomy, including partial ureterectomy, any open approach including rib resection; complicated because of previous surgery on same kidney
• 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 – Nephrectomy with total ureterectomy and bladder cuff; through separate incision
• 50240 – Nephrectomy, partial

If the urologist chooses a laparoscopic approach, your options change to:

• 50543 – Laparoscopy, surgical; partial nephrectomy
• 50545 – Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota’s fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy)
• 50546 – Laparoscopy, surgical; simple nephrectomy, including partial ureterectomy
• 50547 – Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor
• 50548 – Laparoscopy, surgical; nephrectomy with total ureterectomy.

Test Your Knowledge in Different Situations

The best way to know you are reporting procedures correctly is through real-life scenarios. Read the following four cases, decide how you would code it, and then check your answers on page ____.

Scenario 1: The surgeon began a case planning to perform a robotic partial nephrectomy. However, he converted to a radical nephrectomy because of extensive tumor involvement of the kidney. Should both a partial and radical nephrectomy be billed?

Scenario 2: The urologist performs an open renal exploration, which leads to his decision to perform an open radical nephrectomy. What code(s) should be billed?

Scenario 3: The surgeon performs an open partial nephrectomy, but then performs a radical nephrectomy based on the frozen sections (pathology) report of the partial nephrectomy specimen indicating positive margins or incomplete resection of the tumor.