How to code for robotic cystolithotomy, diverticulectomy

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A patient has a large bladder stone (~3.5 cm), part of which is trapped in a bladder diverticulum. How should I bill robotic cystolithotomy along with robotic diverticulectomy?

There are no specific codes for either the laparoscopic (robotic) diverticulectomy nor cystolithotomy. From a pure coding perspective, the proper code would thus be 51999 (Unlisted laparoscopy procedure, bladder). When submitting an unlisted code for a procedure, you of course need to submit your documentation and we recommend a cover letter or explanation of the service including a comparative value or charge based on a similar code. Your staff is likely aware that you may be able to attach supporting documentation electronically at the time you submit the claim through your practice management system or clearinghouse to save some time.

If we explore codes outside of the laparoscopic (robotic) code series, CPT does have codes 51050 (Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection) and 51525 (Cystotomy; for excision of bladder diverticulum, single or multiple [separate procedure]). According to the National Correct Coding Initiative, you should code only 51050, as code 51525 is included in 51050. Note that unbundling is never allowed. This type of bundling edit is common with codes designated as “(separate procedures).”

When reporting the unlisted code, we would recommend including a value-based comparison to code 51050 that may also include a documented increase in work effort due to the size of the stone and inclusion of the diverticulectomy, if appropriate (ie, the procedure took 150% of the time for a standard cystolithotomy due to large size of the stone and difficulty of extracting the stone from the diverticulum including repair of the bladder).

As an alternative, some payers may be willing to accept the 51050-22. The description of procedure code 51050 does not specify the procedure as open in the description.

However, the approach of using the traditionally “open” procedure code for a laparoscopic (robotic) procedure is not widely accepted, thus our initial recommendation for code 51999. The method of coding for laparoscopic codes using traditional “open approach” codes has been endorsed by some payers and is mentioned as an option for coding by AUA representatives for the laparoscopic (robotic) cystectomy.

As is common with these difficult coding conundrums, we encourage you to check with the payer prior to reporting in this way.

I am an endourologist at the University of Michigan with a question regarding coding of percutaneous tumor resection of a large upper tract urothelial cancer. For these cases, I perform a cystoscopy and retrograde pyelogram (52005, 74420) to assist my colleague with getting percutaneous access (50395). I then perform a resection of the tumor percutaneously. This is quite an involved surgery that is more similar to a percutaneous nephrolithotomy than anything else. My coders tell me that despite the complexity of the surgery (sometimes it takes 3 hours), we are supposed to use the renal endoscopy with biopsy code (50555, work relative value unit 6.5) rather than nephroscopy through nephrotomy codes (50574, etc.). The difference in RVU is tremendous. What are your thoughts on how to code a percutaneous tumor resection? I would expect it to be closer to a PCNL.

Your list of codes (descriptions listed in table below) for establishing the access—52005, 74420-26—and your colleague’s (assuming he/she is from a different specialty/practice) coding of 50395 are accurate.

We are puzzled by your coders’ recommendation to use code 50555 (Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy), when code 50562 (Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with resection of tumor) appears to be more descriptive of the procedure, assuming that you are using renal endoscopy to resect the tumor as the overall question implies.

CPT Code Value Comparison

Code Description Work RVU Facility Total RVUs Global
50080 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm 15.74 25.12 090
50395 Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous 3.37 5.16 000
50555 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy 6.52 9.88 000
50562 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with resection of tumor 10.9 16.81 090
52005 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; 2.37 3.86 000
74420-26 Urography, retrograde, with or without KUB 0.36 0.5 000
Source: Adapted from the Centers for Medicare & Medicaid Services data by Ray Painter MD and Mark Painter; CPT codes and descriptions only, copyright AMA 2018

Code 50562 does carry a 90-day global as opposed to code 50555, most likely due to the longer follow-up required for a treatment as opposed to a diagnostic biopsy. As you can see from the table, code 50562 has a work RVU closer to the PCNL code 50080.

In summary, you would bill Medicare 50562, 52005 (if billing to a private payer, add modifier –51), and 74420-26, and your colleague would bill 50395.

If you are performing the resection without the use of renal endoscopy, your coders may be referencing a different code set for which there is no resection of tumor code.

For vasectomy coding, when is it appropriate to use 55450 instead of 55250? My coder is telling me that 55450 is an outdated code that should no longer be used.

Code 55450 carries the description “ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure),” while code 55250 is for “vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s).”

Recommended: Practice ‘report card’ tracks performance

Most vasectomies are reported with code 55250, as the vas deferens is either divided or a portion of the cord is removed and the ends of the severed or removed cord that remain are clipped or sutured (ligated).

Code 55450 remains an active CPT code and can be used to report a sterilization procedure in which the vas deferens is ligated with a suture and no portion of the cord is removed or cut.

Your coder’s comments likely reflect the popularity of the procedural approach and billing pattern commonly used by other urology practices; however, the code is still active and available for use.