Try Your Skills at Coding Kidney Procedures
See how you score with this nephrectomy quiz! When it comes to nephrectomy coding, the details matter. Many questions need to be asked before you can make the correct code choice, such as: Accurate coding starts with a careful review of the operative report. Put your nephrectomy knowledge to the test with this quiz. Question 1: A patient undergoes a laparoscopic nephroureterectomy. Under general anesthesia, the urologist places the patient in the prone position, creates four access sites below the rib cage, and inserts a laparoscope and trocars. The urologist surgically removes the right kidney and part of the ureter. Which procedure code(s) should you report? Answer: Because the urologist removed the right kidney in its entirety as well as part of the right ureter connected to the bladder, you would report 50546 (Laparoscopy, surgical; nephrectomy, including partial ureterectomy) on your claim. Make note: If the urologist performed a partial nephrectomy and removed only the diseased or infected portion of the kidney, you would report 50543 (… partial nephrectomy) instead. If your urologist performed a radical nephrectomy, use 50545 (… radical nephrectomy (includes removal of Gerota’s fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy), which covers the removal of the kidney, Gerota’s fascia, perinephric fat, a ureter section, possibly the adrenal gland, and regional lymph nodes. If your urologist performs the nephrectomy through a laparoscope along with the removal of a section of the ureter, you’ll still report 50546. Finally, you’ll report 50548 (… nephrectomy with total ureterectomy) if your urologist performs a nephrectomy with a total removal of the ureter. Question 2: If a physician performs bilateral nephrectomies but only transplants one of the kidneys, is it appropriate to report 50365 (Renal allotransplantation, implantation of graft; with recipient nephrectomy) with modifier 50 (Bilateral procedure) appended to illustrate the work of the bilateral nephrectomies despite only a unilateral transplant being performed? Answer: It would be inappropriate to report code 50365 appended with modifier 50 for this scenario. Instead, you should report code 50365 along with the additional appropriate nephrectomy code from the following choices depending on the scenario: Make note: You should append modifier 51 (Multiple procedures) for the nephrectomy that the surgeon performs without a second transplant. Modifiers RT (Right side) and LT (Left side) would also be applicable in this scenario. Question 3: Should you code services separately when a urologist performs an adrenalectomy that involves work on the adrenal gland and the kidneys? Answer: You should not separately report an adrenalectomy with a procedure code like 50545 due to the code descriptor already including the adrenal gland removal. Medicare’s National Correct Coding Initiative (NCCI) also includes an adrenalectomy as part of a simple nephrectomy, which doesn’t include removal of Gerota’s fascia or lymphadenectomy, bundling the open and laparoscopic adrenalectomy codes with all nephrectomy codes. Keep in mind: While radical nephrectomy codes encompass adrenalectomy, surgeons do not always remove the adrenal gland. If you report 50545 and the adrenal gland remains intact, there should be no reduction in services for the excluded adrenalectomy. All radical nephrectomies, whether open or laparoscopic, still include an adrenalectomy. However, if code 50545 is the major procedure and the physician doesn’t remove the adrenal glands, there is no reduction considered, and adding modifier 52 (Reduced services) is unnecessary. Question 4: A gynecologic oncologist performs a total abdominal hysterectomy (TAH) treatment of a left ovarian mass. During the procedure, the surgeon opens the retroperitoneal space, and identifies and traces the left ureter from the pelvic brim to the bladder to facilitate dissection of the ovarian mass from the pelvic sidewall. Following the gynecologic procedure, the urologic surgeon then performs a left partial nephrectomy. How can you determine whether the ureteral dissection represents a separately reportable ureterolysis (50715 [Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis]) versus work that is inherent to the hysterectomy or necessary exposure for the partial nephrectomy? Answer: First, you’ll need to review the full descriptor for 50715, which specifies ureterolysis for retroperitoneal fibrosis. The procedure is performed to release a ureter that has become encased or compressed by dense fibrotic tissue. In other words, code selection is driven by the underlying diagnosis and the purpose of the dissection. In the scenario described above, the surgeon traced and identified the ureter to facilitate removal of the pelvic mass. That work appears to represent surgical exposure and protection of the ureter rather than a true ureterolysis procedure. Although the work for 50715 depicts an open abdominal approach, the key factor is not the approach itself but the presence of retroperitoneal fibrosis or similarly dense adhesions encasing the ureter. The purpose of the procedure is to free the ureter from constricting fibrotic tissue so normal urinary drainage can occur. You could consider adding modifier 22 (Increased procedural services) if the documentation shows substantial additional physician work beyond what is typically required. However, based on the details provided, there is not enough evidence of significantly increased complexity or effort to justify modifier 22. If the ovarian mass made the procedure more difficult or prolonged the dissection, you should clearly document the additional time and circumstances to support the addition of modifier 22. Also, remember that 58150 (Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)) includes removal of the ovaries when performed. This means routine identification, mobilization, or tracing of the ureter necessary to safely complete the hysterectomy and adnexal surgery would generally be considered part of the primary procedure rather than a separately reportable service. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
