Urology Coding Alert

Key: Avoid overcoding accusations and denials when your urologist also performs a cystectomy.

Urinary diversions are commonplace in urology Practice , but coding for these procedures is anything but ordinary. Multiple code options and co-surgeon coding rules complicate urinary diversion cases -- but if you follow four tips, you'll choose the correct code every time.

1. Let Conduit vs. Continent Diversion Guide Your Coding

When your urologist says he performed a urinary diversion, your first step toward the proper code is to determine whether he used a conduit or continent diversion procedure.

If your urologist performed a conduit, you'll choose one of the following codes:

• 50815 -- Ureterocolon conduit, including intestine anastomosis
• 50820 -- Ureteroileal conduit (ileal bladder), including intestine anastomosis (Bricker operation).

If, on the other hand, he performed a continent diversion, choose between these two codes:

• 50825 -- Continent diversion, including intestine anastomosis using any segment of small and/or large intestine (Kock pouch or Camey enterocystoplasty)
• 50810 -- Ureterosigmoidostomy, with creation of sigmoid bladder and establishment of abdominal or perineal colostomy, including intestine anastomosis.

Scour your urologist's documentation for clues as to which procedure he actually performed. "I look for the words 'conduit,' 'ileal,' 'neobladder,' 'stoma,' 'pouch,' and 'colostomy,'" says Samantha Daily, billing specialist for Urologic Consultants in Portland, Ore. "Most of the time two or more of those words are listed somewhere in the op report."

Conduit: There are two types of conduit your urologist may perform: an ileal conduit involves the small bowel and a colon conduit involves the large bowel utilizing either the sigmoid colon or the transverse colon. Conduit procedures, as the name implies, all have incontinent stomas requiring the continuous wearing of a drainage appliance.

Continent diversion: Alternately, continent diversion procedures include an abdominal or pelvic pouch, composed of the small and/or large bowel. They involve a continent stoma, which must be periodically catheterized to empty the pouch.

The difference: "A urinary conduit is outside the body," explains Susan Finnegan, RHIT, CCS, CPC, a coder in Boston. "For instance, in an ileal conduit, a piece of the small bowel is placed at the skin surface to form a stoma and the ureters are attached to the other end" of the conduit within the abdominal cavity. There is no urine storage within a conduit. On the other hand, a continent diversion is "inside the body," such as by creating an interior pouch for the urine, Finnegan explains.

2. Cystectomy Changes Your Coding Options

Urinary diversions are often associated with cystectomies. If your urologist performs a cystectomy along with a urinary diversionary procedure, you would not use one of the above mentioned codes, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. Instead, you should choose from one of the following three codes:

• 51590 -- Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis
• 51595 -- ... with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes
• 51596 -- Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder.

Using one of these three codes is the only way the urologist will be paid properly for the cystectomy and conduit/diversion, Daily warns.

Pointer: Unlike 51595, the descriptor for 51596 does not include pelvic lymphadenectomy. If your urologist performs a pelvic lymphadenectomy in addition to the 51596 procedure, report the lymphadenectomy separately using 38770 (Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes [separate procedure]). Append modifier 50 (Bilateral procedure) if your urologist performs a bilateral lymphadenectomy.

3. Laparoscopy Leads to Unlisted Codes

If your urologist uses a laparoscopic technique to perform the urinary diversion, you'll need to use several unlisted procedure codes.

Example: "CPT does not have a specific code for laparoscopic construction of an ileal conduit. Therefore, you will report this procedure with three unlisted codes,"

Ferragamo says. You'll code the procedure as follows:

• 44238 (Unlisted laparoscopic procedure, intestine) for the ileal conduit
• 50949 (Unlisted laparoscopic procedure, ureter) for the ureteroneoenterostomy
• 44187 (Laparoscopy, surgical; ileostomy or jejunostomy, non-tube) for the laparoscopic ileostomy.

4. For Un-Diversions, Code With 50830

If your urologist documents that he performed an "undiversion" rather than a urinary diversion, you should not be looking at any of the previously mentioned codes. Instead, you'll use 50830 (Urinary undiversion [e.g., taking down of ureteroileal conduit, ureterosigmoidostomy or ureteroenterostomy with ureteroureterostomy or ureteroneocystostomy]).

How it works: "During un-diversion, the urologist 'takes down' or removes a urinary diversion such as an ileal or sigmoid conduit and reimplants the ureters into the bladder or into each other and then into the bladder," Ferragamo explains.

Variation: If your urologist only takes down or removes an ileal or colonic conduit without ureteral implantations, then you should append modifier 52 (Reduced services) to 50830.

Example: Your urologist removes an ileal conduit and replaces it with a continent diversion. You would report 51596 for the construction of the continent diversion and 50830-52 for the removal of the previously performed ileal conduit.