Urology Coding Alert

Question: How should I code for a hand-assisted laparoscopic total nephroureterectomy with open distal ureterectomy and excision of a bladder cuff? The patient had a malignant tumor of the mid ureter.

Iowa Subscriber

Answer: You should report 50548 (Laparoscopy, surgical; nephrectomy with total ureterectomy) for the laparoscopic total nephroureterectomy. Then, include 50650 (Ureterectomy, with bladder cuff (separate procedure)) for the open distal ureterectomy and excision of the bladder cuff.

Append modifier 59 (Distinct procedural service) for non-Medicare payers or modifier XS (a separate structure) or XU (an unusual non overlapping service/procedure, separate/different technology) for Medicare carriers to 50650 to break the bundle with 50548. You can break this Correct Coding Initiative (CCI) bundle since this latter procedure is an ipsilateral “open lower abdominal” procedure that represents a separate and distinct operative incision/approach involving another part of the urinary tract.

Note: The open surgical procedure is not a conversion from a failed laparoscopic procedure to an open procedure but represents an additional procedure to fully treat the pathology. Both procedures were necessary to treat this patient, and therefore, both should be billed and both should be paid.