Urology Coding Alert

Question: Our provider performed a laparoscopic excision of an intra-abdominal secondary malignant tumor with left ureterolysis for harvesting for a tumor-infiltrating lymphocyte study. The extent of tumor was approximately 4 cm in greatest dimension. The left ureterolysis was needed to remove the left ureter from its adherent position on top of all the tumor and the iliac vessels. The surgeon also noted that the procedure was especially difficult due to the extent of fibrosis and tumor overlying all normal structures. This extended the duration of the procedure by at least 50 percent. What’s the CPT^® coding?

Arkansas Subscriber

Answer: This is an especially tricky operation to code due to the fact that no existing CPT^® codes perfectly align with the documented services. With respect to the tumor excision, you’ll have to report 49329 (Unlisted laparoscopy procedure, abdomen, peritoneum and omentum) since the closest resembling code is an open procedure, 49203 (Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less).

In reporting 49329 on your paper claim, you should factor in the additional time and effort needed to complete the procedure in Box 19. Furthermore, you will include 49203 as the closest resembling comparison code. In order to document the time and effort needed to complete this portion of the service, you should append modifier 22 (Increased procedural services) to 49203 in Box 19. You should also include a copy of the operative report and a highlighted portion of the report that justifies the use of modifier 22. In these instances, a physician’s note further justifying the need for modifier 22 can go a long way.

Next, you’ve got to consider the coding for the left ureterolysis. The surgeon documented that the ureterolysis was necessary in order to fully excise the tumor. However, similar to the excision coding, no existing code within the CPT^® code book perfectly fits for the documented services. While 50715 (Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis) may seem to fit the bill, this service is reported when performed for retroperitoneal fibrosis diagnoses. Instead, you will report 50949 (Unlisted laparoscopy procedure, ureter) and include 50715 as the closest comparison code in Box 19. Keep in mind that there does not appear to be any documentation to support appending modifier 22 to 50715 for this portion of the service.

Coder’s note: You may initially feel inclined to perform a National Correct Coding Initiative (NCCI) edits check on comparison codes 49203 and 50715. However, existing NCCI edits between these codes should not play a role in your decision to report two unlisted codes separately. NCCI edits take the exact details of each respective code into consideration when making bundling determinations, so using two similar procedures as comparison codes does not necessarily mean a bundling edit will trigger for the two unlisted services reported. However, this determination will be left up to the payer who may deny payment for the ureterolysis as performed as indicated when the two benchmarked codes are billed together.