Urology Coding Alert

Hand-assisted laparoscopy (HAL) is a relatively new method for doing many urological surgeries, but there are no codes for HAL. A laparoscopy doesnt pay as much as open surgery. For proper reimbursement, urologists have several options, including using the unlisted code, appending modifier -22 to the laparoscopic code or just billing the straight laparoscopic code.

Urologists could be using the HAL technique for any number of procedures performed on the kidney, ureters or adrenal gland. Some of the open surgical procedures and their laparoscopic parallels include the following:

Kidneys
Open procedure (50220-50240, nephrectomy)
Laparoscopic (50545-50548, laparoscopy, surgical)

Adrenal
Open procedure (60540, adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal [separate procedure])

Laparoscopic (60650, laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal)

Ureter
Open procedure (50610-50630, ureterolithotomy)
Laparoscopic (50947, laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral stent placement)

Appending Modifier -22 to the Laparoscopy Code

The main question is whether to bill modifier -22 (unusual procedural services) or not. Some urologists recommend appending modifier -22 to the laparoscopic code for HAL. In an open procedure, the wound is open and the urologist performs the surgery with his or her hands in the wound. In a laparoscopic procedure, the hands arent used; the laparoscope goes in through an incision, and instruments go in through separate small incisions called ports. In hand-assisted laparoscopies, there are several incisions one for the scope, one for the instruments and one for the hand. One port has the scope with the camera, and the other has the surgical instruments. The procedure is still technically a laparoscopy, even though one hand is in a separate incision in hand-assisted laparoscopy. But due to the difference, modifier -22 is an option.

Open Procedures and Modifier -52 or -22

Some urologists say you should use the laparoscopy procedure code and the open procedure code with modifier -52 (reduced services) on the open code. For example, for a nephrectomy with partial ureterectomy, you would bill CPT 50546 (laparoscopy, surgical; nephrectomy, including partial ureterectomy) and 50220 (nephrectomy, including partial ureterectomy, any approach including rib resection) with modifier -52 appended to the 50220. Modifier -22 increases payment on the laparoscopy, and modifier -52 decreases payment on the open procedure. Some urologists believe they should be able to code HAL procedures as open procedures because HAL is more work than an open procedure.

Arthur Tarantino, MD, head urologist at Connecticut Surgical Group, a 35-physician, nine-urologist practice in Hartford, has been using modifier -22 on the open procedure code to bill for HAL. Tarantinos group has performed more than 200 HAL renal procedures in the past two and a half years. Straight lap codes do not do justice to the procedure, in that they are grossly under- reimbursed as compared to open surgery, Tarantino says. Furthermore, there is no reason to apply the reduced services code to the open surgical code because hand-assisted renal surgery is more difficult than open surgery. We now code the open surgical code plus modifier -22 for more unusual services with an applied percentage.

But Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stonybrook, advises against billing HAL as open. You can only use the code for what youre doing, he says. Youre not doing an open procedure, so you shouldnt code for it.

Although HAL requires special skill and is better for the patient than an open operation, a code must be chosen based on the work done, Ferragamo says. Choosing a code based on its ability to pay more leads to fraud.

Using the Unlisted Code

There is a good argument for using the unlisted code for HAL. CPT guidelines state that if there is no existing code accurately describing the service provided, report the unlisted code for the appropriate organ/body system, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding and compliance consultancy in Denver. For urological laparoscopies, this would be 50549 (unlisted laparoscopy procedure, renal). Correct coding would direct me to report the unlisted laparoscopy code, Page says. In addition to the operative report, I always include a letter of explanation from the physician stating the reason for the unlisted code (e.g., CPT coding guidelines) and the rationale used to establish the charge (e.g., complexity of procedure, additional physician skill needed, risk to the patient, etc.).

Laparoscopic Code Is a Safe Choice

Urologists can also bill the straight laparoscopy codes without appending modifier -22.

Morgan Hause, CCS, CCS-P, coding compliance specialist at Urology of Indiana, a 17-urologist practice in Indianapolis, bills HALs as straight laparoscopies. Our physicians consider the extra incision (in HAL) to be another port, Hause says. The hand is considered a surgical instrument.

The second incision alone does not justify modifier -22 on the laparoscopic codes, Hause says. Its not uncommon in laparoscopic procedures to have to make a second incision, he notes.

The fact that HAL is better for the patient than open surgery doesnt mean you should be paid more for it, Hause says. The idea of being able to provide a cutting-edge service like hand-assisted laparoscopies is to be able to help the patient, he says. Our physicians say its easier anyway, because they have better control of the field.

Ferragamo agrees and recommends the straight laparoscopy codes as the most accurate method of coding for hand-assisted laparoscopies. The only change in the procedure (from straight laparoscopies) is that the surgeons hand substitutes for an instrument via an enlarged port, he says. Although this aids in performing the procedure, it is still a laparoscopy.

The surgeon must choose a coding option for hand-assisted laparoscopy that fits the circumstances. As always, check with the payer to maintain medical and billing compliance.