Urology Coding Alert

Tip: Surgical approach and procedure determines your radical nephrectomy code choice

If you're altering your radical nephrectomy coding based on whether your urologist removes the patient's adrenal gland, you're setting yourself up for miscoding and lost reimbursement. Whether the physician performs the surgery laparoscopically or as an open procedure, you'll have to choose whether you need to report either a radical or a simple nephrectomy. Follow these expert tips to ensure you choose the right code every time.

Simple Nephrectomies Aren't Always Your Best Option

When your urologist performs a radical nephrectomy but doesn't remove the adrenal gland, you may be tempted to report a simple nephrectomy code such as 50220 (Nephrectomy, including partial ureterectomy, any open approach including rib resection) or 50546 (Laparoscopy, surgical; nephrectomy, including partial ureterectomy). However, you should select a radical nephrectomy code, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

For a radical nephrectomy, choose one of the following codes based on the procedure's surgical approach components, says Chandra Hines, business office manager for NC Urological Associates Inc. in Raleigh, N.C.:

• 50230--Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy

• 50545--Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota's fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy).

"Use either of these two codes when a radical nephrectomy is performed whether or not the urologist removed the adrenal gland," Ferragamo says. Also, Correct Coding Initiative (CCI) edits bundle the adrenalectomy into the radical nephrectomy, so conversely if the urologist removes the adrenal gland at the time of the radical nephrectomy, you would not typically code it separately.

Explanation: "Over the years, urologists have realized that removal of the adrenal gland is not always necessary, and leaving the adrenal behind during a radical nephrectomy does not appear to compromise cure rates," Ferragamo says. "The American Urological Association's Reimbursement and Coding Frequently Asked Questions and Answers has told us as recently as August of 2006 that you can report a radical nephrectomy if you perform all other components but leave the adrenal gland behind."

Hint: The diagnosis may be a correct coding clue. Typically, urologists perform radical procedures for malignancy, and simpler procedures for benign disease.

Don't Fret Over Reduced-Service Modifiers

When your urologist leaves the adrenal gland during a radical nephrectomy, you may be tempted to append modifier 52 (Reduced services) to the procedure code to show that the urologist didn't perform the full procedure. The AUA has suggested that you not attach a modifier but report the full service, a radical nephrectomy.

Example: Your urologist performs a laparoscopic radical nephrectomy, removing the kidney, Gerota's fascia, and the adrenal gland, and performs a localized lymphadenectomy. Another urologist may elect to do a laparoscopic radical nephrectomy, removing the kidney and surrounding fascia but leaving behind the adrenal gland. As explained above, in either case you should code a radical nephrectomy for both urologists.

Old way: In the past, urologists would bill 50545-52, a reduced laparoscopic radical nephrectomy, because all of the elements of the procedure had not been performed. Insurance carriers often ignored modifier 52 and paid the full fee, or at times paid a fee reduced by 10 to 20 percent, or did not immediately reimburse for the service, requesting further documentation before issuing a payment, usually reduced.

New way: Just report 50545 based on the surgical approach. You'll be paid the entire surgical fee.

Success: "We code the full radical nephrectomy procedure even when the urologist does not remove the patient's adrenal gland," Hines says. "I don't always receive the same results because carriers vary so much, but most pay on the full procedure."

"If our society (the AUA) suggests a specific coding protocol, you at least have the society to stand behind you if you're questioned about your billing or coding. You should not be accused of fraud or of improper coding," Ferragamo says.