Urology Coding Alert

Question: A patient with a tumor that was confirmed radiologically in his renal pelvis was scheduled for a nephroureterectomy. Before the surgery, the patient attended a healing service in church. He suspected his tumor was gone, and he asked the urologist to confirm this before removing the kidney and ureter. Upon exploration and pyelotomy, the urologist did not find the tumor. How should I code this?


Georgia Subscriber

Answer: For the procedure, report 50120 (Pyelotomy; with exploration), assuming the urologist did not feel any abnormality on palpation of the renal pelvis and therefore chose to open the renal pelvis to be sure the tumor was there before removing the kidney and ureter. If he did nothing further besides close the incision after finding no tumor, 50120 is the correct procedure code.

For a diagnosis to establish the medical necessity for the exploration that was negative, report ICD-9 code 793.5 (Nonspecific abnormal findings on radiological and other examination of body structure; genitourinary organs [filling defect, kidney]) as the primary diagnosis and the reason for the surgery.

As a secondary diagnosis, report V65.5 (Person with feared complaint in whom no diagnosis was made) for the problem that turned out to be nonexistent and a normal renal pelvis with no tumor or abnormality. Another possible secondary diagnosis: V71.1 (Observation for suspected malignant neoplasm).