Urology Coding Alert
Just 2 Codes Can Capture Complicated Surgery
Question: My urologist noted in a operative report that she performed a radical cystectomy, radical hysterectomy and bilateral salpingo-oophorectomy, urethrectomy, bilateral pelvic lymph node dissection, Indiana pouch urinary diversion, and bilateral ureteral stent placement. What codes should I report, and do I need modifier 50 on the codes for the bilateral procedures? Should I bill for a complete pelvic exenteration?
Iowa Subscriber
Answer: First, report 51596 (Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder) for the radical cystectomy, Indiana pouch formation, and urethrectomy.
Then, report 58210 (Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling [biopsy], with or without removal of tube[s], with or without removal of ovary[s]) for the radical hysterectomy, removal of tubes and ovaries, and bilateral pelvic node resection.
Watch out: The cystectomy code includes the stent placement so you should not separately report that part of the procedure. Also, you should only bill the complete pelvic exenteration code when the rectum is also removed.
You do not need modifier 50 (Bilateral procedure) with either of these codes.
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