sidney01@roadrunner.com
Contributor
my physician assisted as well as was lead surgeon with multiple surgeries on one patient. One of the procedures was the above. I cannot figure out what to code this as. Can anyone give me their opinion? Thank you!
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Wiki Attempted resection pelvic mass
- Thread starter sidney01@roadrunner.com
- Start date
I think that we will need more info in order to give you any advice. The term "pelvic mass" can mean so many different anatomic locations, types of masses, and different possible surgical approaches that it would be impossible to code without knowing the exact details of the case, as well as which physician performed what part of the procedures.
Please post your op note and I would be happy to give my opinion.
thanks!
Please post your op note and I would be happy to give my opinion.
thanks!
sidney01@roadrunner.com
Contributor
I think that we will need more info in order to give you any advice. The term "pelvic mass" can mean so many different anatomic locations, types of masses, and different possible surgical approaches that it would be impossible to code without knowing the exact details of the case, as well as which physician performed what part of the procedures.
Please post your op note and I would be happy to give my opinion.
thanks![PROCEDURE PERFORMED:
Abdominal exploration, extensive lysis of abdominal adhesions, attempted
resection of pelvic mass, ureterolysis, left ureteral reimplantation
with a psoas hitch.
FINDINGS:
Extensive abdominal adhesions were noted. These were taken down, and we
were able to identify the pelvic mass. Initially the pelvic mass was
mobilized pretty freely on 3 sides. We were able to take the bladder
down, resect distally and laterally; however, as we began resecting the
more proximal side, it was apparent that there was intimatly
involvement with the colon. It became extremely difficult to try to
remove this off of the sacrum. We had not lost any blood at that point;
however, we were afraid that because of the dense adherence
surrounding vascular structures because of the very dense adherence
to the sacrum and other pelvic sidewall structures that continued
resection would still leave positive margins, and the risks of bleeding
and complications were not worth the resection. We then looked at what
was most likely causing her significant pain, which was her obstructed
ureter, and so ureterolysis was completed from the point where the
ureter went into the pelvic mass up to the kidney. At this point, the
bladder was mobilized anteriorly and laterally and was attached with
permanent sutures to the fascia of the psoas muscle. Extravesical,
speculated, tension-free watertight ureteral implant was completed. A 5
x 22-cm stent was placed for structure. The bladder was closed in a
watertight fashion. Catheter was placed. A JP was placed in the area
of the repair. Sponge, needle, and towel count was correct. There were
no bowel injuries with resection. The wound was closed.
DESCRIPTION OF PROCEDURE:
After informed consent, Ms. ________ was taken to the operating room. This was a surgery done in combination with myself and Dr. _____. She was
sterilely prepped and draped. She was placed in a low lithotomy
position on the field. A catheter was placed. We then opened the
abdomen with a periumbilical extended midline incision. The fascia was
opened, and the underlying adhesions were taken down. We were able to
mobilize the colon and the small bowel for allowing retraction into the
proximal abdomen. At this point, I began to focus on the left side, we
were mobilizing the bladder off of the anticipated mass. We are able to
find the mass and dissect distally along the sidewall, and we are able
to get a plane around the mass, but the mass was never free and mobile.
It was still densely adherent to the sacrum in the more proximal
attachment points. As we were dissecting it off of the bladder, we did
make a couple of the cystotomies, but these were quickly identified and
close primarily, and on water test, noted to be repaired. It was at
this point, as stated above, that continued resection was deemed to be
futile, and for that reason, we decided to stop continued resection of
the mass. It did have a necrotic appearance. We noticed this because
as we were resecting it we started resecting into the mass because the
plane was just not opening itself up. It was at that point that we
realized that there was no way we were going to get clear margins for
this particular resection. So we opted to change gears and to try to
affect the thing that was going to reduce her pain the most and that was
the severely obstructed left kidney. The left ureter was identified.
The very dense retroperitoneal fibrosis was mobilized off the ureter.
We continued to mobilize off the iliacs and resect upward toward the
kidney. This allowed for free mobility of the ureter. It was then
severed at the level of the entry into the mass and a copious amount of
fluid was drained from the left kidney and the kidney then started
producing copious amounts of urine. At this point, the bladder was
mobilized anteriorly to recreate the space of Retzius. We mobilized it
laterally to allow for the bladder to be pulled over toward the left
psoas muscle. A 0 Prolene suture was then placed in the serosa of the
bladder and into the psoas tendon to allow the bladder to be pulled in
the direction of the left ureter. Two-point fixation was completed.
The bladder was then opened. A cystotomy was made for the passage of
the ureter. The ureter was spatulated. We attempted to do an
intravesical repair, but the tension was just too much, so we opted to
do a tension-free watertight extravesical repair. This was repaired
using 4-0 Monocryl. Once the posterior edges were sutured in place, the
stent was placed. A wire was passed up the ureter, and then over the
wire, the stent was added. At this point, the closure was completed in
an interrupted fashion. The bladder was then closed in 2 layers, first
a 3-0 chromic mucosal repair and then a 0 Vicryl full-thickness closure.
The bladder was then irrigated. The repair was noted to be watertight.
Hemostasis was meticulously obtained. Surgicel was then placed
posterior to the dissected ureter where we dissected off the vessels
just to ensure hemostasis and then more was placed in the space of
Retzius. The sponge, needle, and towel count was correct. The bowels
were evaluated. There were no perforations. The wound was copiously
irrigated with antibiotic solution. The fascia was closed with a
running 0 PDS. The skin was closed with staples. Prior to closure of
the wound, a JP was placed in the left lower quadrant, a 10 flat at the
level of anastomosis. Foley catheter was left to gravity. Sterile
dressings were then added. No immediate complica/QUOTE]
The codes I have used are:
49000 (81) assisted
49005 (81) assisted
53500
51565
99221 (25)
But I do not know what to do with the resection of pelvic mass or am I totally off with this? Thank you and sorry so long but this was a complicated procedure. Appreciate your help so very much.
Quite the operation...
This a definitely a complicated case and one that does not come up all that often. I coded urology for 6 years and can't say that I have seen another one like it, although there are a couple that are similar. Your long and complicated procedure warrants a long and complicted response. There are a few things to touch on here with the op note and the codes that you have selected. Hope this helps!
1.) It would be helpful to have the size of the tumor and the physician's opinion as to where the tumor originated. The size being dictated in the op note will affect code selection on a lot of different tumor and lesion excision CPT codes. It should be your doctor's normal practice to include these in every op note just to be safe and avoid the chance of leaving money on the table. More on tumor size later on...
2.) As far as your code selection, I think you are off base with the codes that you listed. Here's my thoughts why for each code, and the I'll get into my codes as well:
49000: Explore Laparotomy - This is only billed when there is not another more involved procedure taking place. Since this is a complicated operation with more than just exploration taking place, this code would not be appropriate.
49005 ? - This is not a valid CPT code. I'm not sure if you meant to go with a different code and just mistyped this instead. (If you meant 44005 for enterolysis, it is bundled into all major procecures and cannot be unbundled)
53500: Urethrolysis, transvaginal, secondary, open, including cystourethroscopy - This is for a transvaginal approach to fix the urethra, not an open abdominal surgery on the ureters which is the case with your operation. Different approach, different tube, different anatomic location.
51565: Cystectomy, partial, with reimplantation of ureter(s) into bladder The main part of this procedure is a partial cystectomy (bladder removal) and this did not occur.
99221(25): E/M billing on the same day as a major procedure is not appropriate except in a very rare instance. This seems like a planned procedure so there would be no rational instance where a separate E/M code should be reported.
3.) I have two CPT codes that I would go with for this proceudre. The order of these codes will change depending on the 4920x code that you use (see below). If 49203 is used it will be the second listed code, but 49204 or 49205 will be the first listed code based on RVU order. In either case, a 51 modifier is needed for the secondary code.
50785-LT: Ureteroneocystostomy; with vesico-psoas hitch or bladder flapThis is defined in the op note where the physician severs the ureter at the level of the mass, and then describes how the ureter was reimplanted into the bladder through a cystotomy and with internal fixation. he also notes "A 0 Prolene suture was then placed in the serosa of the
bladder and into the psoas tendon to allow the bladder to be pulled in
the direction of the left ureter." which is the vesico-psoas hitch. Of importance, the ureterolysis is bundled into this code and there is not justification for it to be unbundled.
495203-49205: Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors I listed a range of 3 codes because they depend on size. 49203 is for tumors less than 5 cm in dimeter, 49204 is for tumors 5.1-10 cm iin diameter, and 49205 is for tumors greater than 10.0 cm. You will have to either question the doctor and have them document the size of the tumor in the note, or default to the smallest size and code with 49203. Between 49203 and 49205 there is a difference of 15 RVUs, which will significantly affect the amount that is reimbursed. This translates to a difference of almost $600 that could be left on the table if the tumor size is missing and you have to downcode a case that could have been coded to a bigger size. Also, Your doctor should not need to modify this code because they elected to leave the tumor in place and terminate the attempt at resection. The work was still performed and they deserve to be paid for it.
As far as an assistant surgeron modifier, I'm not sure your rationale for using modifier 81 which is minimum assistant surgern, when modifier 80 for assistant surgeon is available. All you will do is reduce your reimbursement when there is no reason to. Was the other doctor that performed the surgery truly the primary surgeon and your physician just the assistant, or were they both ascting a primary "co-surgeons"? This is a potential opportunity to use modifier 62: two surgerons if they were acting as co-surgerons and not primary and assistant. In this case, each physician is acting with equal responsibility, and each doctor would require their own op note in order to bill. Instead of getting paid a minimum rate for being the assistant surgeon, each physician needs to increase their billed fee to 125% of the original fee, and then each surgeon is paid 62.5% of the reimbursement, which is also raised to 125% of the normal allowable.
This a definitely a complicated case and one that does not come up all that often. I coded urology for 6 years and can't say that I have seen another one like it, although there are a couple that are similar. Your long and complicated procedure warrants a long and complicted response. There are a few things to touch on here with the op note and the codes that you have selected. Hope this helps!
1.) It would be helpful to have the size of the tumor and the physician's opinion as to where the tumor originated. The size being dictated in the op note will affect code selection on a lot of different tumor and lesion excision CPT codes. It should be your doctor's normal practice to include these in every op note just to be safe and avoid the chance of leaving money on the table. More on tumor size later on...
2.) As far as your code selection, I think you are off base with the codes that you listed. Here's my thoughts why for each code, and the I'll get into my codes as well:
49000: Explore Laparotomy - This is only billed when there is not another more involved procedure taking place. Since this is a complicated operation with more than just exploration taking place, this code would not be appropriate.
49005 ? - This is not a valid CPT code. I'm not sure if you meant to go with a different code and just mistyped this instead. (If you meant 44005 for enterolysis, it is bundled into all major procecures and cannot be unbundled)
53500: Urethrolysis, transvaginal, secondary, open, including cystourethroscopy - This is for a transvaginal approach to fix the urethra, not an open abdominal surgery on the ureters which is the case with your operation. Different approach, different tube, different anatomic location.
51565: Cystectomy, partial, with reimplantation of ureter(s) into bladder The main part of this procedure is a partial cystectomy (bladder removal) and this did not occur.
99221(25): E/M billing on the same day as a major procedure is not appropriate except in a very rare instance. This seems like a planned procedure so there would be no rational instance where a separate E/M code should be reported.
3.) I have two CPT codes that I would go with for this proceudre. The order of these codes will change depending on the 4920x code that you use (see below). If 49203 is used it will be the second listed code, but 49204 or 49205 will be the first listed code based on RVU order. In either case, a 51 modifier is needed for the secondary code.
50785-LT: Ureteroneocystostomy; with vesico-psoas hitch or bladder flapThis is defined in the op note where the physician severs the ureter at the level of the mass, and then describes how the ureter was reimplanted into the bladder through a cystotomy and with internal fixation. he also notes "A 0 Prolene suture was then placed in the serosa of the
bladder and into the psoas tendon to allow the bladder to be pulled in
the direction of the left ureter." which is the vesico-psoas hitch. Of importance, the ureterolysis is bundled into this code and there is not justification for it to be unbundled.
495203-49205: Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors I listed a range of 3 codes because they depend on size. 49203 is for tumors less than 5 cm in dimeter, 49204 is for tumors 5.1-10 cm iin diameter, and 49205 is for tumors greater than 10.0 cm. You will have to either question the doctor and have them document the size of the tumor in the note, or default to the smallest size and code with 49203. Between 49203 and 49205 there is a difference of 15 RVUs, which will significantly affect the amount that is reimbursed. This translates to a difference of almost $600 that could be left on the table if the tumor size is missing and you have to downcode a case that could have been coded to a bigger size. Also, Your doctor should not need to modify this code because they elected to leave the tumor in place and terminate the attempt at resection. The work was still performed and they deserve to be paid for it.
As far as an assistant surgeron modifier, I'm not sure your rationale for using modifier 81 which is minimum assistant surgern, when modifier 80 for assistant surgeon is available. All you will do is reduce your reimbursement when there is no reason to. Was the other doctor that performed the surgery truly the primary surgeon and your physician just the assistant, or were they both ascting a primary "co-surgeons"? This is a potential opportunity to use modifier 62: two surgerons if they were acting as co-surgerons and not primary and assistant. In this case, each physician is acting with equal responsibility, and each doctor would require their own op note in order to bill. Instead of getting paid a minimum rate for being the assistant surgeon, each physician needs to increase their billed fee to 125% of the original fee, and then each surgeon is paid 62.5% of the reimbursement, which is also raised to 125% of the normal allowable.
Last edited:
sidney01@roadrunner.com
Contributor
Thank you so very much! I appreciate your advise! As you can tell I am new to urology and needed guidance of a more experienced urology coder. I really appreciate you and your experience!