Urology Coding Alert

Question: A patient had an adrenal tumor and a renal tumor, as well as peritoneal lymphadenopathy. The urologist did an adrenalectomy, a partial nephrectomy, and dissected out some of the lymph nodes in the peritoneum. I am stuck on the lymph nodes. The op report states "The bowel itself looked normal; however there were palpable lymph nodes in the mesentery. Several of these lymph nodes were dissected out and excised." Would the lymph node excision be incidental to the other procedures?

Minnesota Subscriber

Answer: First, you'll report CPT 50240 (Nephrectomy, partial) for the partial nephrectomy. Then, report CPT 60540 (Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal [separate procedure]) for the adrenalectomy. Append modifier 59 (Distinct procedural service) to override the Correct Coding Initiative (CCI) bundle between 50240 and 60540.

Reasoning: Because there is also an independent tumor in the adrenal, and the adrenalectomy is a separate procedure from the nephrectomy for the renal tumor, you are justified in breaking the bundle with modifier 59 because there were two separate tumor removals for two separate organs. However, you should include the removal of a normal adrenal gland with a radical total or partial nephrectomy, especially for an upper pole renal tumor, and therefore, in both cases, you should not separately code the adrenal gland removal.

Plus: You should code -- and get paid for -- the lymph node excision the urologist performed. You'll report 38564 (Limited lymphadenectomy for staging [separate procedure]; retroperitoneal [aortic and/or splenic]) for the "staging" lymphadenectomy.

The lymphadenectomy you describe was not therapeutic, but the removal of several nodes was to determine the spread of the tumors or "stage." Staging a tumor helps determine the need for further therapy, such as chemotherapy, along with the surgical tumor removal.