Urology Coding Alert

Question: Below is my provider’s surgical note. As documented, they performed a robot-assisted laparoscopic prostatectomy with bilateral pelvic lymphadenectomy and removal of foreign bodies. Our provider wants to bill 49402 for the removal of the Urolift implants with ICD-10-CM code T19.1XXA. The coders are comfortable with the CPT^® codes for the procedure, but disagree on the diagnosis coding. Can you advise?

Procedure: Robot-assisted laparoscopic radical prostatectomy with bilateral nerve-sparing and bilateral pelvic lymphadenectomy and removal of foreign bodies

The scalpel was used to make an incision to the left of the umbilicus through which the Veress needle was placed. The abdomen was insufflated and a 12 mm port was placed. The scope was then used to guide placement of the remaining three 8 mm ports. The robot was docked and the remainder of the procedure was done robotically.

The seminal vesicles and vas were dissected posteriorly in the rectal cul de sac. The bladder was dropped away from the anterior abdominal wall. The pelvic lymphadenectomy was then performed bilaterally removing the lymph nodes between the external iliac vein and obturator nerve from the femoral canal to the bifurcation of the ilia vessels. The endopelvic fascia was incised, and the bladder was then released from the base of the prostate. The posterior plane between the prostate and the rectum was developed bluntly and nerve-sparing was performed bilaterally using Hem-o-lok clip on the pedicles with the release of the neurovascular bundles all the way to the apex.

The patient had a history of Urolift procedure that he had not told us about as the anchors were found protruding from the prostate including two that were into the bladder. These needed to be removed, so three total were dissected out and sent to pathology as gross only specimens. No further metal anchors were left in place that were visible.

The dorsal vein complex and urethra were then divided and the prostate was placed in an EndoCatch bag. The dorsal vein ligating suture was placed and pexed to the anterior pubic symphysis to perform urethral suspension for postoperative support of the urethrovesical anastomosis complex for continence.

The posterior reconstruction was then performed, and then a running vesicourethral anastomosis was performed using double-armed Biosyn suture in watertight fashion such that a J-P drain was not required. The specimens were then extracted through the periumbilical incision. The fascia was closed with Ethibond. All port sites were closed with Biosyn and Dermabond. The procedure was terminated.

AAPC Forum Subscriber

Answer: You should report diagnosis code C61 (Malignant neoplasm of prostate) for the robot-assisted laparoscopic prostatectomy with bilateral pelvic lymphadenectomy and removal of foreign bodies procedures. Code T19.1XXA (Foreign body in bladder, initial encounter) is not appropriate because the foreign body is not in the bladder.

For the procedures performed, report the following:

• 55866 (Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed) for the robot-assisted laparoscopic radical prostatectomy with bilateral nerve-sparing. Note that this code include the nerve-sparing and the urologist’s use of the robotic equipment.
• 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy) for the bilateral pelvic lymphadenectomy. Unlike the code for the open approach (55845, Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes), 55866 does not include lymphadenectomy.

Note: CPT^® code 49402 (Removal of peritoneal foreign body from peritoneal cavity) is not appropriate for removal of the Urolift implants since the urologist performed the procedure for prostate cancer and the cancerous tissue in the prostate has to be removed, Storck warns.

“The prostatectomy is performed for prostate cancer. The tissue is going to be removed by laser anyway so the removal of the Urolift is not reportable,” explains Stephanie Stinchcomb Storck, CPC, CPMA, CCS-P, ACS-UR, longtime urology coder and consultant in Glen Burnie, Maryland.