Urology Coding Alert

If that headline gives you pause, its probably because you think a bilateral nephrectomy is a medical impossibility. Thats what Medicare thinks too. But, in fact, there may be a case in which both of a patients kidneys must be removed.

For example, a patient with end stage renal disease on hemodialysis for chronic renal failure for three years develops uro-sepsis secondary to bilateral renal abscesses. The abscesses were discovered by cat scan. Both kidneys are contracted.

The code for a simple nephrectomy is 50220 (nephrectomy, including partial ureterectomy, any approach including rib resection). Medicare will not allow modifier -50 (bilateral procedure) to be used with 50220 because removal of both kidneys in the same session would be a medical impossibility/improbability. But medical practice has proven Medicare wrong. The patient did have both kidneys removed. Now the urologist is faced with the difficult problem of how to bill Medicare for the work.

Dual Use of Modifiers

Normally, you would think the code would be 50340-50 (recipient nephrectomy [separate procedure]). But, there was no transplant in this case. Ray Painter, MD, a urologist who is president of PRS, a Denver, Colo.-based reimbursement and coding consultant, recommends the following solution:

Code the procedure 50220-22-50. The modifier -22 tells Medicare that unusual procedural services were performed. The modifier -50 tells what those unusual procedures were a double nephrectomy. The modifier -50 is blocked, because in most cases you would not do this, says Painter. But in this case, it was done. You would have to send all documentation to the carrier to show that both kidneys were removed, Painter concludes.