Urology Coding Alert

Question: How should we code for a retroperitoneal exploration and debridement for a stone that was extruded from a pyonephrotic kidney three months after a nephrectomy?

Pennsylvania Subscriber  
Answer: Sometimes a stone is left in the flank area after a nephrectomy. If there are no problems no infection, no pain the stone can stay there. If the stone causes an infection, however, it must be removed and the area debrided and drained. This requires exploring the flank and performing an incision and drainage of the abscessed material. Use 49010 (exploration, retroperitoneal area with or without biopsy[s] [separate procedure]) for the exploration if only a retroperitoneal exploration is performed. Use only 49060 (drainage of retroperitoneal abscess; open) if a retroperitoneal incision and drainage is performed.
 
There is never an extra fee for the exploration if billing for the drainage. Code 49060 is a comprehensive code, and 49010 is bundled into it. According to CPT and the Correct Coding Initiative, 49010 is never payable with 49060. No modifier will allow a bypass edit.  
Answers to Reader Questions and You Be the Coder were contributed by Michael A. Ferragamo, MD, clinical assistant professor of urology at the State University of New York, Stonybrook; Sandy Page, CPC, CCS-P, co-owner, Medical Practice Support Services in Denver; and Laura Siniscalchi, RHIA, CCS, CCS-P, CPC, senior consultant with Deloitte and Touche in Boston.