Urology Coding Alert

Hand-assisted laparoscopy (HAL) is a relatively new method for doing many urological surgeries, but there are no codes for HAL. A laparoscopy doesnt pay as much as open surgery. For proper reimbursement, urologists have several options, including using the unlisted code, appending modifier -22 to the laparoscopic code or just billing the straight laparoscopic code.

Urologists could be using the HAL technique for any number of procedures performed on the kidney, ureters or adrenal gland. Some of the open surgical procedures and their laparoscopic parallels include the following:

Kidneys
Open procedure (50220-50240, nephrectomy)
Laparoscopic (50545-50548, laparoscopy, surgical)

Adrenal
Open procedure (60540, adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal [separate procedure])

Laparoscopic (60650, laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal)

Ureter
Open procedure (50610-50630, ureterolithotomy)
Laparoscopic (50947, laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral stent placement)

Appending Modifier -22 to the Laparoscopy Code

The main question is whether to bill modifier -22 (unusual procedural services) or not. Some urologists recommend appending modifier -22 to the laparoscopic code for HAL. In an open procedure, the wound is open and the urologist performs the surgery with his or her hands in the wound. In a laparoscopic procedure, the hands arent used; the laparoscope goes in through an incision, and instruments go in through separate small incisions called ports. In hand-assisted laparoscopies, there are several incisions one for the scope, one for the instruments and one for the hand. One port has the scope with the camera, and the other has the surgical instruments. The procedure is still technically a laparoscopy, even though one hand is in a separate incision in hand-assisted laparoscopy. But due to the difference, modifier -22 is an option.

Open Procedures and Modifier -52 or -22

Some urologists say you should use the laparoscopy procedure code and the open procedure code with modifier -52 (reduced services) on the open code. For example, for a nephrectomy with partial ureterectomy, you would bill CPT 50546 (laparoscopy, surgical; nephrectomy, including partial ureterectomy) and 50220 (nephrectomy, including partial ureterectomy, any approach including rib resection) with modifier -52 appended to the 50220. Modifier -22 increases payment on the laparoscopy, and modifier -52 decreases payment on the open procedure. Some urologists believe they should be able to code HAL procedures as open procedures because HAL is more work than an open procedure.

Arthur Tarantino, MD, head urologist at Connecticut Surgical Group, a 35-physician, nine-urologist practice in Hartford, has been using modifier -22 on the open procedure code to bill for HAL. Tarantinos group has performed more than 200 HAL renal procedures in the past [...]