Urology Coding Alert

Question: The urologist had to convert a laparoscopic procedure to an open procedure because of unforeseen complications. The patient is covered by Medicare. How do I report this change?

Maryland Subscriber

Answer: Under Medicare guidelines, anytime a laparoscopic procedure is converted to an open procedure you should only bill the open procedure. Therefore, only report the open procedure for this claim. Your diagnosis should also include ICD-10-CM diagnosis code Z53.31, laparoscopic surgical procedure converted to open procedure.

Some commercial insurers will allow you to also bill the laparoscopic procedure in addition to the open procedure. You should append either modifier 52 (Reduced services) or modifier 53 (Discontinued procedure) to the laparoscopic procedure code.