Urology Coding Alert

Question: I'd appreciate some help with how to bill for the following scenario for a patient with a vena cava thrombus during a kidney removal: Physician A and an assistant physician B, both in the same group, performed an open radical nephrectomy without taking regional lymph nodes. A vascular surgeon was called in to help with the evacuation of vena cava thrombus, which he performed with the assistance of physician A. Because the vascular surgeon is new to this area and is not credentialed, he will not be billing for his portion of the procedure.

Tennessee Subscriber

Answer: You should bill 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy) for physician A and 50230-80 (Assistant surgeon) for physician B. Strictly speaking a radical nephrectomy includes removal of the kidney with Gerota's fascia and the perinephric fat. Notice that this code also describes nephrectomy with regional lymphadenectomy and/or vena caval thrombectomy. However, the fact that lymph nodes were not taken doesn't impact the code choice, and you do not report this as "reduced services."

Since physician A performed the radical nephrectomy and participated in the thrombectomy for which the vascular surgeon is not billing, you should list surgeon A as the primary surgeon and surgeon B as the assistant. Recall that an assistant surgeon doesn't have to be present for the entire procedure or all parts of the procedure. Also note that a thrombectomy can vary from a fairly minor component to an extensive thrombectomy reaching as high as into the right atrium. Whether Surgeon A performed or assisted at the thrombectomy, and since the vascular surgeon will not be billing for his part of the procedure, Surgeon A should still bill as the primary surgeon with 50230 without modifiers.

Caveat: There are a couple of other factors you should take into consideration. For one thing, you should bill this code for Surgeon A only if he describe the thrombectomy as part of his op note, even if it says the vascular surgeon also worked on it. However, if surgeon A documents only that he assisted the vascular surgeon "see his note for details" or something like that, you should not list 50230. Instead, you should bill only for the nephrectomy (e.g., 50220, Nephrectomy, including partial ureterectomy, any open approach including rib resection) and leave the thrombectomy money on the table. Without a description of the thrombectomy as part of surgeon A's report, it would never stand up to review if that was needed.

Final caution: Some payers are pretty tough on the subject of having physicians who are not credentialed with the payer providing services for their patients. You need to be aware of payer rules before you bill this case.