Wiki I got introuble by the boss when I billed out 51595 please help me clear this up!!

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janetjanuary said:
:confused:Good Morning,

I have a situation in where I have two surgeons who performed a procedure:
Robotic assisted radical cystoprostatectomy with pelvic lymph node dissection. An ileal conduit urinary diversion. Please make note that Dr. Matthew Sand was the primary surgeon for the ileal conduit urinary diversion.

I billed it out as 51595 on two separate claims with modifier 62 on each claim and was later demoted by my manager  is this is incorrect.? What CPT code's should I have listed?
Please review copied op notes, first op notes listed is the Op Notes from the Attending Physician then the next Op notes are for the 2nd Surgeon who performed only the ileal conduit urinary diversion.

Op notes from Primary Surgeon
INDICATIONS: This patient is a 77-year-old Caucasian male who was diagnosed with muscle invasive bladder cancer. Multiple management options were discussed with the patient including that of observation, radical cystoprostatectomy, pelvic lymph node dissection as well as chemotherapy and radiation. A discussion of neoadjuvant chemotherapy was also undertaken with the patient and it was decided the patient would best benefit from immediate radical cystoprostatectomy and pelvic lymph node dissection with ileal conduit urinary diversion for treatment of his bladder cancer. Risks, benefits, and alternatives of the procedure including that of bleeding, infection, postoperative stay and hospital course were also discussed. Risk of ileus and bowel related complications as well as urinary related complications were also discussed. It was decided to move forward with the procedure. Consent was signed and obtained.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, placed on the operating room table in supine position. Appropriate anesthesia and antibiotics given, the patient was positioned, prepped and draped in the usual sterile fashion. Pneumoperitoneum was established using Veress needle insufflation. Laparoscopic and robotic ports were placed across the abdomen in standard fashion. Upon entering the abdomen, the patient was noted to have some minor adhesions in the right lower quadrant related to previous appendectomy and hernia surgery. These adhesions were taken down laparoscopically without complication.
Once these adhesions were taken down laparoscopically, the robot was docked over the patient and robotic instruments were placed in their respective ports. The console portion of the procedure began by mobilizing the sigmoid colon off of the left lateral pelvic sidewall. Once this was complete, the ureters on both the right and left side were isolated by incising the peritoneum over the crossing or bifurcation of the iliac vessels. Ureters were dissected and freed down to their intramural portion and then insertion into the bladder. Once the ureters were identified, dissected and isolated down to their entry into the bladder, ureters were clipped at the level of the bladder on both the right and left side and separated from their insertion points. More proximal dissection of the ureters were also undertaken by freeing up peritoneal and ureteral adventitial attachments so as to gain maximal length on the ureters for future ileal conduit diversion.
Once ureteral dissection was completed, attention was then taken to the lateral portion of the dissection where the perineum was incised lateral to the medial umbilical ligaments and dissection was carried out on both the right and left side down to the level of the endopelvic fascia on the lateral border of the prostate. Endopelvic fascia was incised on both the right and left side. The vas deferens was identified on both the right and left side and taken down as well as it coursed through the peritoneum. By doing this, the space of Retzius was entered. Anterior abdominal wall attachments were preserved. The space posterior to the bladder was also created by incising the peritoneum on the underside of the bladder. The rectal was dissected off of its attachments posteriorly to prostate. The seminal vesicles were identified as dissection was carried out posteriorly underneath the prostate completely. The pedicles on the prostate as well as the bladder were then isolated. Once these pedicles were isolated on both the right and left side, using the 10 millimeter LigaSure instrument, they were appropriately transected and sealed without complication. Once again, both on the right and left side. Once posterior attachments were taken down and both pedicles of the bladder as well as prostate were taken down, and it was clear that the prostate was freed posteriorly as well as laterally, the anterior abdominal wall attachments of the bladder were then taken down. The apex was then isolated and oversewn using a CT-1 needle and #0 Vicryl suture so as to oversew the dorsal vein complex. Dorsal vein complex was then transected down to the urethra. Once again, lateral and posterior attachments of the prostate were appropriately freed as were the apical attachments. Hem-o-Lok Weck clips were then used to clip the urethra so as to maintain a closed oncologic system. Once this was done, the urethra was then transected without complication. The bladder, prostate, seminal vesicles as well as pelvic lymph nodes were freed en bloc and placed in a 15 millimeter EndoCatch bag. A 24-French Foley catheter with 40 milliliters in the balloon was placed per urethra and left as a pelvic drain on mild traction to ensure hemostasis. Hemostasis in the prostate and bladder bed was achieved using pinpoint electrocautery as well as fibrillar hemostatic agent. Once the specimen was placed in a bag, pelvic lymph node dissection ensued by removing the external iliac and internal iliac lymph nodes on the right side, the external and internal iliac lymph nodes were removed en bloc with the specimen on the left side.
Once this lymph node dissection was completed, the ureters from the left side was tunneled underneath the sigmoid colon using robotic and laparoscopic techniques and brought over to the right side. Each ureter was then tagged appropriately using a 5-7 inch Monocryl stitch once again for easy identification during the ileal conduit portion of the procedure. Once the ureters were tagged appropriately and tunneled underneath the sigmoid colon, it was decided the patient will be moved on to the second stage of the case, the ileal conduit urinary diversion. For this, please refer to Dr. Matthew Sands' dictation.
Once the ileal conduit urinary diversion was completed and the stoma was completed, the patient had a JP drain placed in one of the left lateral robotic ports. JP drain was placed on bulb suction and secured to the skin using a 3-0 nylon suture. Midline incision was closed using looped #1 PDS in a running fashion. The skin level was closed using 4-0 Vicryl suture. Overall, the patient tolerated the procedure well. The patient left the operating room with an ileal conduit urinary diversion, bilateral ureteral stents exiting the urinary diversion, Foley catheter draining the pelvis, a 24-French with 40 milliliters in the balloon, and a JP drain on bulb suction. Once again, the patient tolerated procedure well, was taken to recovery room in stable condition with plans for admission and observation.

Op notes from the 2nd Surgeon

DESCRIPTION OF PROCEDURE: I entered the operating room after the bladder had been removed and placed into an EndoCatch bag and both ureters had been well-mobilized using a robotic technique. The left ureter had been passed under the sigmoid mesentery and both ureters were clipped in the right lower quadrant. His umbilical camera incision port was extended inferiorly and superiorly for a total incision length of approximately 8 centimeters. Bovie electrocautery was used to divide the subcutaneous tissues and the fascia was identified and incised longitudinally. The rectus muscle was divided and the abdomen was entered at this time. Next, the ileocecal valve was identified and 15 centimeters proximal to the ileocecal valve, the conduit was demarcated. The conduit was measured to be approximately 12 centimeters in length; 3-0 silk pop offs were used through the serosa to demarcate the conduit. Next, the mesentery was divided in standard fashion using Bovie electrocautery to make windows in the mesentery and LigaSure to divide the mesenteric vessels. After the mesentery was divided in the proximal and distal segments of the conduit, attention was then turned to staple division of the bowel segment. Using an Endo-GIA stapler, the proximal and distal conduit was separated from the remaining ileum. This was done without complication. The conduit was laid inferiorly and attention was then turned to the ileoileal anastomosis. Again, stapled anastomotic technique was used with Endo-GIA stapler used to create the side-to-side anastomosis. After the side-to-side anastomosis had been created using the Endo-GIA, a TA stapler was then used to close the butt of the anastomosis. There were no complications with this. Next, the mesenteric trap door was closed using interrupted 2-0 silk suture through the interior mesenteric layer. The butt staple line of the ileoileal conduit was buried using a 2-0 Vicryl in lembert fashion to bury the staple line. At this time, the ileoileal anastomosis was returned into the abdomen and attention was then turned to the ureteroileal anastomoses. The distal end of the left ureter, was incised sharply and sent as a distal margin. The ureter was spatulated with Potts scissors and a small opening in the medial side of the ileal conduit segment was made with electrocautery. Next, an interrupted anastomosis was made with 4-0 Vicryl suture, connecting the spatulated ureter to the ileoileal conduit. Prior to closing the entire anastomosis, a single J ureteral stent was passed through the conduit using a Yankauer sucker to pass the stent coming out through the anastomotic site and passed down the ureter into the kidney without complication. The stent was left in place and the remaining anastomotic sutures were placed to create a complete anastomosis. At this time, attention was then turned to the contralateral side where a similar procedure was performed with sitting the distal ureter on the right side for permanent specimen, spatulating the ureter and creating a stented interrupted 4-0 Vicryl anastomosis between the ileal conduit and the ureter. No complications with this. Stent was passed easily again. At this time, attention was then turned to creating the stoma. The right lower robotic port was then opened circumferentially using electrocautery and the fascia was split in a T formation using electrocautery. A Babcock was placed through this incision into the abdomen and then grasped up the distal aspect of the conduit with stents and brought through the skin. The conduit was approximated to the subcutaneous tissues using a 3-0 Vicryl in interrupted fashion and the conduit was rose budded to the skin using a 4-0 Vicryl suture in interrupted fashion. At this time, a JP drain was placed into the left lower robotic port and the fascia was closed using a #1 PDS loop closure in a running fashion. Skin was closed with 4-0 Monocryl and all wounds were dressed with Dermabond. There were no complications in my portion of the procedure. The patient was awoken from anesthesia, extubated and brought to recovery room in stable condition

I Thank You very Sincerely for taking the time to read my email! And would Sincerely appreciate any help you may suggest as I work for a Large Urology practice here in Atlanta and not just for me but for the Surgeons who are performing procedure's like this every day. Also if you would rather call me my number is office 770-801-2588 or after working hours cell 678-524-8139.
Thank You again!
Click to expand...
It dismays me that your manager chose to demote your rather than provide helpful instruction for the correct codes.
This was not an open procedure which is where your logic took a bad turn. Also there is no one code that will combine the bladder excision and the prostate excision. When you break it down into the separate parts you have a code for the robotic assisted laparoscopic prostatectomy which is the 55866, and then you are left with the cytectomy and lymph node disection for which there is no code, I would not use a 22 modifier in this case but I would use the 51999 and compare it to 51575.
for the second surgery again there is no laparoscopic code for the ileal conduit diversion so you will need to use the 50949 and compare it to the 50820.
that is how I would have coded these notes.
A handy book to have in the surgical field is the "Coders Desk Reference for Procedures" by Ingenix. It can help you rock thru coding surgeries.
However when you have a note that indicates laproscopic approach you do not code it as an open procedure, it you have to use an unlisted then do so but compare it to the open procedure code you would have used.
 
CPT code for revision of Ileal loop conduit diversion

My doctor did below procedure. Ileal loop conduit was already done in 2014 and now doctor did revision of that in 2015. Please help me for this.

PROCEDURE: Revision of ileal loop conduit diversion with repositioning on anterior abdominal wall.

POSTOPERATIVE DIAGNOSIS: History of neurogenic bladder with retracted ileal loop conduit.

PROCEDURE IN DETAIL: The patient was taken to the OR, laid in a supine position. Appropriate anesthesia was administered. Her abdomen was prepped and draped in a standard surgical fashion. A circumferential incision was made around the original ileal loop conduit. It appeared to have been retracted, and there was a large dimple in the area, and due to patient's body habitus the phalange for the urostomy bag was not adherent. After dissecting out with meticulous dissection the conduit through the subcutaneous tissue, the fascia was entered, and the rectus muscle was exposed, and the conduit was dissected around the rectus muscle to the fascia level. The fascia was opened, and this allowed for freeing of the ileal loop further to allow mobilization to its new site. Next, after further pulling the loop out, it was secured to the fascia with some interrupted 2-0 Vicryl suture. The previously marked site for the new conduit stoma was then excised circumferentially, and some of the subcutaneous tissue was dissected. Next,
the dissection was carried down to the fascia and then the ileal loop was tunneled to the new site and brought up. After trimming the edges of the ileal loop, adequate hemostasis was ensured, and then it was secured to the skin in the usual fashion using 2-0 Vicryl suture in an interrupted fashion. A nice rosebud conduit was noted. Adequate hemostasis was ensured. The urostomy bag and phalange were appropriately connected and placed on the anterior abdominal wall, and it appeared to be adherent nicely with no abnormalities.

The previous incision was first irrigated with antibiotic irrigation and then a large flat JP drain was brought out subcutaneously. The incision was closed first by reapproximating the subcutaneous tissue with 2-0 Vicryl suture in a continuous fashion and then the skin with staple clips. Sterile dressings were applied. The needle, instrument, and sponge counts were correct. The patient was extubated and transferred to the recovery room in stable condition.

Thanks in advance!
Yogesh
 
Yogesh, the code you should be looking at is 44314, as JEYCPC posted.

If you are still unsure, take your CPT book to your Dr and tell him/her that you need their assistance with the OP note and show this code and ask if you are on the right track.
 
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