Urology Coding Alert

Question: Two physicians worked on the same case. One performed a right laparoscopic nephrectomy. The other performed a cystoscopy, open right distal ureterectomy and right pelvic lymph node dissection. How should I bill for this case for both physicians?

New Jersey Subscriber

Answer: There are two methods:

1. Bill as if each physician performed separate surgeries. The physician performing the laparoscopic nephrectomy couldnt get the whole ureter, causing the other physician to perform the open procedures.

The physician performing the nephrectomy should bill 50546 (laparoscopy, surgical; nephrectomy, including partial ureterectomy).

The second urologist performed the ureterectomy plus the bladder cuff, and should therefore bill 50650 (ureterectomy, with bladder cuff [separate procedure]), 50700 (ureteroplasty, plastic operation on ureter [e.g., stricture]), 52000 (cystourethroscopy [separate procedure]) with modifier -51 (multiple procedures) appended and 38770 (pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes [separate procedure]), also with modifier -51.

For Medicare, neither physician can charge an assistant fee because each has performed a major procedure at the same sitting. With some private payers, however, you can receive payment for each physician acting as assistant to the other.

As long as each physician is performing his or her respective opening and closing, you can bill the full fee for each with no modifier -52 (reduced services). File the claim on paper, and include a cover letter to explain that this is not a typical situation.

2. Bill for co-surgeons or two primary surgeons. Using this method, each physician bills the same code on a separate HCFA 1500 form: 50548 (nephrectomy with total ureterectomy) with modifier -62 (two surgeons) appended (CPT specifically allows the use of modifier -62 with 50548). Surgeon A performs and dictates the nephrectomy while surgeon B performs and dictates the total ureterectomy (although part is performed as an open procedure). Surgeon B also performs and dictates the cystoscopy (52000) and unilateral pelvic node resection (38770). Surgeon A assists in the node dissection and should therefore append modifier -80 (assistant surgeon) to that procedure. The claim would read as follows:

Surgeon A
50548-62
38770- 51-80

Surgeon B
50548-62
38770-51
52000-51

When using modifier - 62, the global fee for 50548 (90 days) is increased to 150 percent and shared equally between surgeons A and B.

Each claim should be filed on paper, with each surgeons operative report and an explanation of the need for two primary surgeons attached.

The first method is preferred because it generates a higher payment and there is no need for extra reports and delay in payment.

Answers for "Reader Questions" and You Be the Coder" provided by Michael A. Ferragamo, MD, clinical assistant professor of urology at the State University of New York, Stonybrook; and Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services in Denver.