Urology Coding Alert

Question: Our provider performed a bilateral percutaneous renal needle biopsy of both kidneys. The operative report goes into full detail for aspiration of the right kidney, but only indicates that “a similar procedure was performed on the left side.” Is this enough documentation to support a bilateral procedure? If so, how should I report the coding?

Utah Subscriber

Answer: It’s not uncommon to find this kind of verbiage on a biopsy report that indicates a duplicate procedure was performed contralaterally. While the general rule is the more documentation the better, this sort of documentation is not necessarily atypical and does not need to be addended in order to code the procedure bilaterally. You may want to let your provider know that best dictation practices include the details specific to each side — in particular for malpractice defense.

As for the procedure coding, you’ve got to take into account that 50200 (Renal biopsy; percutaneous, by trocar or needle) has a medically unlikely edit (MUE) of 1. This means that you may only report one unit of 50200 on any given date of service (DOS). Reporting 50200 separately with modifiers LT (Left side) and RT (Right side) is inappropriate and will be flagged by the payer.

Instead, make sure to append modifier 50 (Bilateral procedure) to 50200 to ensure the claim meets all the necessary billing requirements.