Urology Coding Alert

Scour the documentation for the cyst location. 

When your urologist performs several procedures in one operative session, it can be difficult to determine how many codes to report to bring in every dollar your surgeon deserves, while also avoiding miscoding and overpayment situations.

Renal surgery is a hotbed of potential coding errors because urologists often perform more than one procedure, and if you don’t know the coding rules, you may submit for more reimbursement than you should. Take a look at the example surgery below:

Procedure: Laparoscopic robotic partial nephrectomy with extensive lysis of adhesions and a laparoscopic renal cyst decortication.

Diagnosis: Renal mass and renal cyst

How would you code this procedure? Follow the three tips below to ensure you get it right every time.

Start with 50543 for Partial Nephrectomy

First, you should report 50543 (Laparoscopy, surgical; partial nephrectomy) for the laparoscopic partial nephrectomy.

Diagnosis help: You should attach diagnosis code 593.9 (Unspecified disorder of kidney and ureter) to 50543 if “renal mass” is the only information your urologist provides. If a radiological study of the kidney discovers a renal mass, but there is no conclusive diagnosis you could also report 793.5 (Nonspecific [abnormal] findings on radiological and other examination of genitourinary organs).

You should not report 239.5 (Neoplasms of unspecified nature of other genitourinary organs) for a renal mass. A note in the ICD-9 manual dictates that “the term ‘mass’ unless otherwise stated is not to be regarded as a neoplastic growth.” A mass such as a mass in the kidney may mean many things including a malignant or benign process, abscess, cyst, or even a normal but hypertrophied portion of the kidney.

“However, if the clinical preoperative diagnosis is ‘renal cell carcinoma,’  a kidney malignancy, determined radiologically by specific CAT or MRI imaging findings,  one may use the ICD-9 diagnostic code 189.0 (Malignant neoplasm of kidney except pelvis),” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook.

ICD-10: In October 2014, when ICD-10 is implemented, you will report either N28.9 (Disorder of kidney and ureter, unspecified) or N29 (Other disorders of kidney and ureter in diseases classified elsewhere) instead of 593.9.

Skip Separate Lysis Coding

You should not separately bill for the laparoscopic lysis of adhesions using 44180 (Laparoscopy, surgical, enterolysis [freeing of intestinal adhesion] [separate procedure]).

“The lysis of adhesions is really getting to the surgical field and pathology, the location where the surgery will be performed, Ferragamo explains.

If, in the operative report, the urologist clearly and specifically notes that the lysis of adhesions required a significant amount of time and prolonged the surgery, then you might want to add modifier 22 (Increased procedural services) to 50543, Ferragamo says. “Use the modifier 22 when the lysis of adhesions adds at least a 50 percent increase in time, and that should be stated clearly in the operative report and a covering letter,” he explains. 

Pitfall: Even though modifier 22 might be warranted in the above example, you cannot assume lysis of average adhesions always merits modifier 22.

“Lysis of adhesions is inherent in most procedures, particularly after a previous surgery,” says Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. and Brooklyn, N.Y. The mere presence of adhesions does not mean you can use modifier 22.

“Everyone has adhesions and there is an expectation that you will lyse them when you encounter them during surgery,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash. “But when the adhesions are dense due to previous surgeries or chronic disease, that’s when you’re looking at modifier 22 work.”

In fact: Many payers tend to deny payment for lysis of adhesions when the physician performs the lysis with other procedures. The reason is that the physician normally destroys the adhesions to gain access to the surgical field, which is a standard surgical technique, Mac says. On the other hand, when adhesions are dense, very vascular, anatomy-distorting, and require extensive work to remove, the payer may consider payment. In those cases, you should append modifier 22 to the primary procedure rather than billing separately for lysis of adhesions.

Be Cautious With Adding 50541

The proper code for the decortication is 50541 (Laparoscopy, surgical; ablation of renal cysts). When your urologist uses laparoscopic treatment of renal cysts, whether it is ablation, excision, decortication, etc., you will report 50541.

The Correct Coding Initiative (CCI) bundles 50543 and 50541. This bundles does have a modifier indicator of “1,” which means that if clinical circumstances warrant, you can break the bundle and report both codes by adding modifier 59 (Distinct procedural service). But with these two codes, there would be few clinical scenarios where modifier 59 would actually be warranted, Ferragamo says.

Exception: “If the renal mass and renal cyst are in separate locations within the same kidney, in other words, if the partial nephrectomy is for an upper pole lesion, and the decortication is for a lower pole cyst, then one may also bill for the surgical ablation of the renal cysts with modifier 59,” Ferragamo explains. If warranted, you would bill 50541-59 with diagnosis code 593.2 (Cyst of kidney acquired) [ICD-10 code: N28.1 (Cyst of kidney, acquired)].