Urology Coding Alert

Question: The surgeon planned to perform a partial nephrectomy with unroofing of a renal cyst in the same kidney. He first unroofed the cyst. As he began the partial nephrectomy, it became obvious that a partial procedure would not work; he performed a radical nephrectomy instead. Does this negate the unroofing of the cyst?

South Carolina Subscriber

Answer: Yes, the radical nephrectomy coding overrides the cyst unroofing. Anytime a major procedure is performed on the same site where a minor procedure has already been performed during the same session, then the minor procedure is considered an integral part of the major procedure.

In this scenario, the major procedure is the radical nephrectomy and the minor procedure is the unroofing of a renal cyst. When the kidney has been completely removed, there is no significance of reporting unroofing of a kidney cyst.

An open radical nephrectomy is coded with 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy). An open partial nephrectomy is coded with 50240 (Nephrectomy, partial). If the urologist performs a partial nephrectomy and shifts to a total radical open nephrectomy during the same encounter because of persistent tumor in the resected kidney, report 50240 as the primary procedure with the higher Relative Value Units (RVUs) and 50230 as the secondary procedure with the lower RVUs. These procedure codes are not bundled so you do not need to append any modifiers. Code 50280 (Excision or unroofing of cyst(s) of kidney) is bundled into both 50230 and 50240 and often is not billable or payable when submitted with 50230 or 50240.