Urology Coding Alert

Question: Our urologist did a cystoscopy and using a Collins knife incised the intramural tunnel surrounding the ureter. He says the bladder wall thinned out in such a way that he felt he would be able to pluck the ureter out intraabdominally. Then, he did a laparoscopic nephroureterectomy (50548) and then did a Gibson incision to prepare to remove the kidney and ureter specimen, but states that at this point before removing the specimen he did an open bladder cuff. Here is an excerpt from the operative report:

“After the ureter was freed as much as possible, we decided to perform open bladder cuff. We made a small 3 inch Gibson incision and then delivered the specimen through that. The intravesical ureter was then resected under direct vision. We ensured that the bladder cuff was also removed along with the ureter. Upon examination of the specimen, it seemed as though we got the entire ureter .  As the hole within the bladder was fairly small, we decided not to close the cystotomy site.”

What is the proper coding for this surgery?

Pennsylvania Subscriber

Answer: First, report 50548 (Laparoscopy, surgical; nephrectomy with total ureterectomy) for the laparoscopic nephroureterectomy (removal of the kidney and retroperitoneal/abdominal ureter). 

Next, report 52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands) for the cystoscopic incision and freeing of the ureteral orifice.

Finally, use 50650 (Ureterectomy, with bladder cuff [separate procedure]) for the removal of the intramural (intravesical) lower ureter with the bladder cuff. 

Don’t miss: You will need to attach modifier 59 (Distinct procedural service), modifier XS (Separate structure), or modifier XU (Unusual non-overlapping service) to 50650 since the Correct Coding Initiative (CCI) bundles 50650 into 50548 but allows its unbundling in a proper clinical scenario with one of the above modifiers. 

In this clinical scenario, 50650 is a distinct procedure performed during the same encounter on a separate structure — the bladder — and performed using different surgical approaches (laparoscopic surgery for the nephroureterectomy and an open procedure for the removal of the bladder cuff and intravesical ureter). Therefore, for Medicare, either of the XS or XU modifier would be correct. However, since not all non-Medicare contractors have programmed for the new modifiers X{EPSU}, use modifier 59 to unbundle the edit for proper payment.