Urology Coding Alert

Question: A patient presents with bilateral renal masses. The mass on the left was removed in an enucleated fashion. The mass on the right was removed in a wedge fashion. According to the operative note, the case was extremely hazardous and difficult and it was necessary for two urologists to perform the case.

The surgeon also requested a -22 modifier (unusual procedural services) for increased difficulty. The Medicare Physician Fee Schedule Database states that 50240 (nephrectomy, partial) is not amenable to the -50 modifier (bilateral procedure) because the RVUs are based on the procedure being performed as a bilateral procedure. Should I just code this as a 50240-22-62?

Georgia Subscriber

Answer: This highlights a common problem for this procedure. First of all, its true that its not technically a bilateral procedure, since one kidney is enucleated (removed from the shell) and the other is only partially removed.

You are correct in that the 150 percent payment adjustment does not apply to CPT code 50240. This procedure could be coded 50240-22. Documentation indicating that the procedure was extremely hazardous and difficult in addition to the fact that it was bilateral certainly should support the use of the modifier -22, and this documentation should accompany the claim.

Although using modifier -62 (two surgeons) does not always require documentation accompanying the claim, the use of this modifier in this particular case (with code 50240) does require documentation be sent to establish the medical necessity for two surgeons. Claims with modifier -22 will be processed on a by-report basis, so you should expect the claim processing to be delayed. I would expect that the payer will consider the unusual nature of the service and will approve an amount that recognizes the additional services.

You probably should not use modifier -62, although you could, technically. You shouldnt use it because this is not the kind of procedure that calls for two surgeons. Its quite possible that Medicare made a mistake and said you cant use the -50 modifier with 50240, but you can use the -62. It should have been the other way around.

Is there any way you can be more fairly paid for this procedure? One option, if you want to push this, is to file 53899 (unlisted procedure, urinary system) using the -LT and -RT modifiers, and indicate in the report you file with the claim that the left side was enucleated and the right was a wedge removal.

Sources for answers to You Be the Coder and Reader Questions: Ray Painter, MD, president of PRS consultants in Denver; Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services in Denver; Patricia M. Salmon, president of Patricia M. Salmon & Associates in Philadelphia; Laura Siniscalchi, RHIA, CCS, CCS-P, CPC, education coordinator at Beth Israel Deaconess Medical Center in Boston.