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Urology Coding Alert

Method of Access Is Key in Determining Codes for Flank Drainage

Published on Sat Dec 01, 2001

Coding for open, laparoscopic or percutaneous drainage of the flank requires a distinction between methods of access, as well as location of the abscess or lymphocele that needs to be drained. There are no specific codes for different kinds of flank drainage procedures, so choosing an appropriate code is challenging.
 
Codes differ for renal and peritoneal abscesses and lymphoceles. There are distinctions between the kinds of drainage: percutaneous which requires radiological guidance as denoted by specific codes and open. Laparoscopic drainage can be done for lymphoceles. Bundling issues must be considered when coding for drainage of two areas.
 
Initial diagnostic tests require specific coding as well. Before the drainage, the urologist will perform an abdominal or renal ultrasound (76770, 76775 or 76778) or a computerized axial tomography (CAT) or computed tomography (CT) scan (74150). 
 
The codes in this newsletter are effective on Jan. 1, 2002.

Renal Drainage

Open drainage: If the patient has a complicated (multiloculated or multiple) perirenal or renal abscess or abscesses, the urologist will probably choose an open method of drainage, says Michael A. Ferragamo, MD, professor of urology at the State University of New York, Stony Brook. Use 50020 (drainage of perirenal or renal abscess; open) for open drainage.
 
Percutaneous drainage: If the abscess is small, single and easily accessible not near major blood vessels the urologist performs a percutaneous drainage and uses 50021 ( percutaneous).
 
Use 75989 (radiological guidance for percutaneous drainage of abscess, or specimen collection [i.e., fluoroscopy, ultrasound, or computed axial tomography], with placement of indwelling catheter, radiological supervision and interpretation) for radiological guidance for 50021. Add modifier -26 (professional component) if the procedure is done in the hospital to indicate that the urologist performed the interpretation but does not own the machine.
 
There is no code for laparoscopic drainage of any abscess, renal or peritoneal. Laparoscopies are used for drainage of noninfected material as the material drains into the peritoneal cavity. Laparascopic drainage is fine for a lymphocele but not for an abscess.

Peritoneal Drainage

Laparoscopic drainage: The laparoscopic code for peritoneal drainage for a lymphocele, which can occur after renal transplantation or retroperitoneal surgery, is 49323 (laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity). There is no code for laparoscopic drainage of a peritoneal abscess because such a procedure would not be performed.
 
Open drainage: Use 49062 (drainage of extraperitoneal lymphocele to peritoneal cavity, open) for open drainage of a lymphocele and 49060 (drainage of retroperitoneal abscess; open) for open drainage of a retroperitoneal abscess. Use 49020 (drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open) for open drainage of a peritoneal abscess.
 
Percutaneous drainage: Use 49061 (drainage of retroperitoneal abscess; percutaneous) for percutaneous drainage of a retroperitoneal abscess and 49021(drainage of peritoneal abscess or localized peritonitis; exclusive of appendiceal abscess; percutaneous) for percutaneous drainage of a peritoneal abscess. Code 49021 for radiological guidance.

Two Procedures at the Same Time

Occasionally there is an infection in the psoas muscle, which began as an infection in or around the kidney. The urologist will need to drain both the psoas (49061 for percutaneous or 49060 for open) and the renal (50021 for percutaneous, 50020 for open) abscesses. Depending on which methods of access are used, append modifier -59 (distinct procedural service) or modifier -51 (multiple procedures). Check the Correct Coding Initiative (CCI) for bundles and the Medicare fee schedule to see which code should be listed first. If bundled, use modifier -59; if not bundled, use modifier -51.
 
For example, the urologist performs a percutaneous renal abscess drainage (50021) and a percutaneous psoas abscess drainage (49061). Code 50021 includes 49061. To bill for both codes, which you should do because two distinct and separate procedures were performed, append modifier -59 to 49061. Modifier -59 is justified because the procedure was performed on a separate site.
 
If, however, the urologist decides to perform both drainage procedures via an open access, modifier -59 is not needed. Code 50020 on the first line of the claim form, and 49060-51 on the second line.
 
Use 75989 for radiological guidance. A complete claim for a percutaneous psoas drainage, percutaneous renal drainage, and guidance would look like this:

 50021
 49061-59
 75989-26

Link diagnosis code 590.2 (infections of kidney; renal and perinephric abscess) to 50021; 567.2 (peritonitis; other suppurative peritonitis) to 49061 and either to 75989.
 
Two Procedures, One After Another
 
 
Some abscesses are postoperative complications. If within the global period, code the drainage with modifier -78 (return to the operating room for a related procedure during the postoperative period) appended.
 
Some extensive abdominal abscesses also require staged drainage: Append modifier -58 (staged or related procedure or service by the same physician during the postoperative period) to 50020.
 
For example, if percutaneous drainage fails to completely drain a perirenal abscess and open drainage is performed, use 50020 for the open drainage; no modifier is needed because 50021 has a zero-day global.
 
However, if percutaneous drainage is performed a week after open drainage, use 50021 with modifier -58 because 50020 has a 90-day global.

Diagnosis Codes

Renal and perirenal abscesses are frequently seen in diabetic patients with renal calculi, obstructive neuropathy, and virulent Gram-negative organisms. The renal and perirenal abscess are less frequently staphylococcal infections bloodborne from distant sites such as skin.
 
Primary diagnosis codes for the procedures discussed in this article are 590.2 or 567.2. Secondary diagnosis codes are 250.4x (diabetes mellitus; diabetes with renal manifestations), 041.4 (bacterial infection in conditions classified elsewhere and of unspecified site; Escherichia coli) and 041.11 ( staphylococcus aureus).

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