Urology Coding Alert

Question: The patient was placed in the prone position, and my urologist prepared the site with an antiseptic solution and draped the patient in a sterile fashion. Under general anesthesia, my urologist made four incisions below the rib cage, through which they inserted a laparoscope for viewing and trocars for insertion of instruments. The kidney was then exposed. The ureter (connection from the kidney to the bladder) and blood vessels were disconnected, and the kidney was removed, along with part of the ureter. Which code should I report on my claim? There are so many options, and I am overwhelmed!

AAPC Forum Subscriber

Answer: You should report 50546 (Laparoscopy, surgical; nephrectomy, including partial ureterectomy) on your claim.

Since CPT^® offers numerous options for a laparoscopic nephrectomy, it can be very overwhelming to choose the right code. You must always check the documentation to ensure you find the appropriate code for your particular scenario.

For example, if the urologist performed a partial nephrectomy and removed only the diseased or infected portion of the kidney, you should report 50543 (Laparoscopy, surgical; partial nephrectomy) instead.

If your urologist performed a radical nephrectomy, you should report 50545 (Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota’s fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy)). Therefore, a radial nephrectomy involves the removal of the kidney, Gerota’s fascia and perinephric fat, a section of the ureter, possibly the adrenal gland, and regional lymph nodes.

If your urologist performs the nephrectomy through a laparoscope along with the removal of a section of the ureter, report 50546 (Laparoscopy, surgical; nephrectomy, including partial ureterectomy).

Finally, if your urologist performs a nephrectomy with a total removal of the ureter, report 50548 (Laparoscopy, surgical; nephrectomy with total ureterectomy).