Urology Coding Alert

Question: Our physicians did a laparoscopic nephroureterectomy with an open intravesical ureterectomy and an open excision of a bladder cuff for a malignant renal pelvic tumor. During the lap portion, the surgeon also did lymph node dissection, as follows: "I removed any residual fatty and lymphatic tissue lateral to the vena cava from the level of the renal artery down to a portion just above the bifurcation of the aorta and vena cava ..."

I have the nephrectomy coded as 50236 with diagnosis codes 189.0 and V64.41. But should I bill the lymph separately? Or, should I use an unlisted code to incorporate the nephrectomy and lymph node dissection?

Minnesota Subscriber

Answer: You should not use 50236 (Nephrectomy with total ureterectomy and bladder cuff; through separate incision) since 50236 represents an open procedure. You also shouldn't use an unlisted code for this procedure. Instead, you should first report 50548 (Laparoscopy, surgical; nephrectomy with total ureterectomy) for the laparoscopic nephrectomy and total ureterectomy.

Then, report 38570 (Laparoscopy, surgical; with retroperitoneal lymph node sampling [biopsy], single or multiple) for the laparoscopic lymph node resection.

Finally, report 50650 (Ureterectomy, with bladder cuff [separate procedure]) for the open lower intravesical ureterectomy and bladder cuff excision. The Correct Coding Initiative (CCI) bundles codes 50548 and 50650. To break the bundle, append modifier 59 (Distinct procedural services) to the column 2 code (50650).

The proper diagnostic code for this procedure is 189.l (Malignant neoplasm of kidney and other and unspecified urinary organs; renal pelvis). You don't need to use V64.41 (Laparoscopic surgical procedure converted to open procedure). This code is unnecessary and inaccurate as a laparoscopic procedure was not discontinued for an open procedure. In this case, both the laparoscopic and open procedure are distinct and necessary for the treatment of the renal pelvic malignant tumor so you should code each as separate procedures.