Urology Coding Alert

Question: Two urologists performed surgery on a patient - one did a urethrectomy, and the other did a cystectomy. They are partners in the same practice. How should I code their work? Which modifier should I use - "two surgeons" or "assistant surgeon"?


New York Subscriber


Answer: Append modifier -62 (Two surgeons) to the surgical codes if one partner did the cystectomy and the other one did the urinary diversion. "Each surgeon should report the co-surgery once using the same procedure code," state the CPT Guidelines for modifier -62.
 
If the two surgeons were not working together as primary surgeons performing distinct parts of the procedure, then one was likely acting as an assistant surgeon. For the assistant surgeon, append modifier -80 (Assistant surgeon), which describes the presence of a second physician in the operating room who acts as an extra pair of hands to assist the primary surgeon.

Solution: Coding for the procedure depends on the gender of the patient. For a female patient, urethrectomy is included in the female cystectomy procedure, and you should not bill the urethrectomy separately. However, you can bill an anterior urethrectomy in the male as a secondary procedure to the primary procedure of total cystoprostatectomy.

Use CPT Codes 53215-52 (Urethrectomy, total, including cystostomy; male; reduced services) for the male anterior urethrectomy. You would need modifier -52 to show that the urologists did not do the complete procedure as described in 53215. Since they had already removed the bladder, the urologists could not have performed a cystostomy.