Urology Coding Alert

Question: How should I code a LT-hand assisted radical laparoscopic nephrectomy of the left kidney with partial removal of ureter in which the urologist did not remove adrenal gland? The diagnosis the physician indicated is malignant renal mass.

Texas Subscriber

Answer: When your urologist performs a radical laparoscopic nephrectomy, including the removal of Gerota's fascia and the perinephric fat, but does not also perform an adrenalectomy, the American Urological Association has instructed that you should still code for the radical laparoscopic nephrectomy using 50545 (Laparoscopy, surgical; radical nephrectomy [including removal of Gerota's fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy]).

Keep in mind: When the surgeon performs a hand-assisted procedure, you won't report any additional codes. Payers consider the hand in the wound an extra portal site not necessitating an additional CPT code or modifier.

You should report diagnosis code 189.0 (Malignant neoplasm of kidney ... except pelvis) for this procedure.