Urology Coding Alert

Question: What CPT^® codes should I submit for “robotic exploration of retroperitoneum with biopsy of periureteral mass/para-caval mass”? The diagnoses are D44.11, D48.9, D41.02, and N13.30.

California Subscriber

Answer: Based solely on the documentation you share, your best option is to report 49321 (Laparoscopy, surgical; with biopsy [single or multiple]) for the robotic exploration and biopsy.

Some of the diagnoses your surgeon suggests appear to be appropriate: D44.11 (Neoplasm of uncertain behavior of right adrenal gland), D48.9 (Neoplasm of uncertain behavior, unspecified), D41.02 (Neoplasm of uncertain behavior of left kidney), and N13.30 (Unspecified hydronephrosis). If possible in the future, avoid using unspecified diagnoses as Medicare and several other payers may deny reimbursement. Therefore, change diagnosis D48.9 to D48.3 (Neoplasm of uncertain behavior of retroperitoneum) and change N13.30 to N13.39 (Other hydronephrosis).