Urology Coding Alert

Question: The urologist prepared the patient by positioning them face down and sterilizing the surgical site. After administering general anesthesia, the surgeon made four incisions beneath the rib cage. A laparoscope and trocars were then introduced for visualization and tool access. The procedure involved the excision and removal of the right kidney and a portion of the ureter. How should this be coded?

Illinois Subscriber

Answer: You should report 50546 (Laparoscopy, surgical; nephrectomy, including partial ureterectomy) on your claim. “The urologist removed the right kidney in its entirety as well as the removal of a part of the right ureter connected to the bladder,” says Stephanie Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coding expert and consultant in Glen Burnie, Maryland.

Remember: If the urologist conducted a procedure where only the affected or infected part of the kidney was excised, the appropriate code to document this would be 50543 (Laparoscopy, surgical; partial nephrectomy) instead.

If your urologist performed a radical nephrectomy, use code 50545 (Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota’s fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy), which covers the removal of the kidney, Gerota’s fascia, perinephric fat, a ureter section, possibly the adrenal gland, and regional lymph nodes. If your urologist performs the nephrectomy through a laparoscope along with the removal of a section of the ureter, report 50546.

If your urologist carries out a nephrectomy involving the complete extraction of the ureter, the appropriate code to document this procedure would be 50548 (Laparoscopy, surgical; nephrectomy with total ureterectomy).

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC