Urology Coding Alert

Question: What is the correct CPT code for a nephrectomy with adrenalectomy and removal of Gerota's fascia? The urologist did not perform a lymphadenectomy or vena caval thrombectomy.

Montana Subscriber

Answer: Your urologist performed some, but not all, of the components of a radical nephrectomy - which means you will have to use modifier -52 (Reduced services) on the CPT code for a radical nephrectomy.
 
The urologist's removal of the adrenal and the Gerota's fascia with the kidney most closely reflects a radical nephrectomy procedure, 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy). But because the physician didn't perform the lymphadenectomy or the vena caval thrombectomy, you should report 50230-52.