Coding Companion for Urology/Nephrology A comprehensive illustrated guide to coding and reimbursement 2015 Contents Getting Started with Coding Companion .............................i Scrotum ..........................................................................328 Integumentary.....................................................................1 Vas Deferens....................................................................333 Arteries and Veins ..............................................................15 Spermatic Cord ...............................................................338 Lymph Nodes ....................................................................30 Seminal Vesicles...............................................................342 Abdomen ..........................................................................37 Prostate ...........................................................................345 Kidney ...............................................................................59 Reproductive ...................................................................359 Ureter ..............................................................................116 Intersex Surgery ..............................................................360 Bladder............................................................................153 Vagina .............................................................................361 Urethra ............................................................................226 Medicine .........................................................................371 Penis................................................................................266 Appendix.........................................................................385 Testis ...............................................................................303 Evaluation and Management ...........................................411 Epididymis .......................................................................318 Index...............................................................................433 Tunica Vaginalis ...............................................................325 CPT © 2013 American Medical Association. All Rights Reserved. © 2014 OptumInsight, Inc. Coding Companion for Urology/Nephrology Contents appropriate endoscopic procedure code 590.2 Renal and perinephric abscess — (Use 50576-50580 (50570–50580) and 50045 or 50120. For additional code to identify organism, 50576 Renal endoscopy through nephrotomy or open renal endoscopy (through nephrotomy such as E. coli, 041.41-041.49) or pyelotomy), with examination only, see pyelotomy, with or without irrigation, 592.0 Calculus of kidney 50570; ureteral catheterization, with or instillation, or ureteropyelography, without dilation of the ureter, see 50572; 592.1 Calculus of ureter exclusive of radiologic service; with biopsy, see 50574. Percutaneous renal 593.4 Other ureteric obstruction fulguration and/or incision, with or without endoscopic procedures (through established 593.81 Vascular disorders of kidney biopsy nephrostomy/pyelostomy) are reported with 599.60 50580 with removal of foreign body or 50551–50562. Urinary obstruction, unspecified — calculus (Use additional code to identify ICD-9-CM Procedural urinary incontinence: 625.6, 788.30-788.39) 55.01 Nephrotomy 599.70 Hematuria, unspecified 55.03 Percutaneous nephrostomy without fragmentation 599.71 Gross hematuria 55.11 Pyelotomy 599.72 Microscopic hematuria 55.21 Nephroscopy 753.3 Other specified congenital anomalies of kidney 55.22 Pyeloscopy 788.0 Renal colic 55.23 Closed (percutaneous) (needle) biopsy of kidney 958.5 Traumatic anuria 55.39 Other local destruction or excision of Terms To Know renal lesion or tissue biopsy. Tissue or fluid removed for diagnostic Anesthesia purposes through analysis of the cells in the 00860 biopsy material. ICD-9-CM Diagnostic foreign body. Any object or substance found in an organ and tissue that does not 189.0 Malignant neoplasm of kidney, except belong under normal circumstances. pelvis Kidney 189.1 Malignant neoplasm of renal pelvis CCI Version 18.3 198.0 Secondary malignant neoplasm of 0213T, 0216T, 0228T, 0230T, 12001-12007, kidney 12011-12057, 13100-13153, 36000, 36400-36410, 36420-36430, 36440, 36600, 199.2 Explanation Malignant neoplasm associated with 36640, 37202, 43752, 50392, 50395, transplanted organ — (Code first The physician examines the kidney and ureter 50562-50570, 50684, 51701-51703, complication of transplanted organ with an endoscope passed through an incision 62310-62319, 64400-64435, 64445-64450, (996.80-996.89) Use additional code in the kidney (nephrotomy) or renal pelvis 64479, 64483, 64490, 64493, 64505-64530, (pyelotomy). After accessing the renal and for specific malignancy) 69990, 76000-76001, 77001-77002, ureteric structures with an incision in the skin 209.24 Malignant carcinoid tumor of the 93000-93010, 93040-93042, 93318, 94002, of the flank, the physician incises the kidney kidney — (Code first any associated 94200, 94250, 94680-94690, 94770, or renal pelvis and guides the endoscope multiple endocrine neoplasia 95812-95816, 95819, 95822, 95829, 95955, 96360, 96365, 96372, 96374-96376, through the incision. To better view renal and syndrome: 258.01-258.03; Use 99148-99149, 99150 ureteric structures, the physician may flush additional code to identify associated Also not with 50576: 50555, 50574, 50955, (irrigate) or introduce by drops (instillate) a endocrine syndrome, as: carcinoid saline solution. The physician may introduce 50974 syndrome: 259.2) contrast medium for radiologic study of the Note: These CCI edits are used for Medicare. renal pelvis and ureter (ureteropyelogram). In 209.64 Benign carcinoid tumor of the kidney Other payers may reimburse on codes listed 50576, the physician passes through the — (Code first any associated multiple above. endoscope an instrument that destroys lesions endocrine neoplasia syndrome: by electric current or incision The physician 258.01-258.03; Use additional code Medicare Edits may insert an instrument to biopsy renal to identify associated endocrine Fac Non-Fac tissue. In 50580, the physician passes syndrome, as: carcinoid syndrome: RVU RVU FUD Status instruments through the endoscope to remove 259.2) 50576 16.34 16.34 A0 a foreign body or calculus, and may pass a 223.0 Benign neoplasm of kidney, except 50580 17.62 17.62 A0 stent through the ureter into the bladder. The physician sutures the incision, inserts a drain pelvis MUE Modifiers tube, and performs a layered closure. 223.1 Benign neoplasm of renal pelvis 50576 80*N/A50511 233.9 Carcinoma in situ of other and 50580 80*N/A50511 Coding Tips unspecified urinary organs * with documentation Medicare References: None If the nephrotomy or pyelotomy is done for 236.91 Neoplasm of uncertain behavior of an additional, significantly identifiable kidney and ureter endoscopic service, report both the © 2014 OptumInsight, Inc. CPT © 2013 American Medical Association. All Rights Reserved. 112 — Kidney Coding Companion for Urology/Nephrology Explanation with contrast; and 74178 if performed first without 74000 Computed tomography directs multiple thin beams contrast in one or both body regions followed by the injection of contrast and further sections in one 74000 Radiologic examination, abdomen; single of x-rays at the body structure being studied and or both body regions. anteroposterior view uses computer imaging to produce thin cross-sectional views of various layers (or slices) of Explanation the body. It is useful for the evaluation of trauma, 74190 tumor, and foreign bodies as CT is able to visualize 74190 Peritoneogram (eg, after injection of air or Films are taken of the abdominal cavity in one view soft tissue as well as bones. Patients are required to contrast), radiological supervision and from front to back. Because an abdominal x-ray remain motionless during the study and sedation interpretation usually precedes another diagnostic imaging may need to be administered as well as a contrast procedure, it is not coded separately unless medium for image enhancement. These codes Explanation performed as a separately identifiable examination. report an exam of the abdomen. Report 74150 if no contrast is used. Report 74160 if performed with A radiographic exam is done on the peritoneal cavity 74010 contrast and 74170 if performed first without to define the pattern of air in the cavity after 74010 Radiologic examination, abdomen; contrast and again following the injection of injection of air or contrast. The physician inserts a needle or catheter in to the peritoneal cavity and anteroposterior and additional oblique and contrast. injects air or contrast as a diagnostic procedure. cone views X-rays are then taken. The needle or catheter is 74174 removed. This code reports the radiological Explanation 74174 Computed tomographic angiography, supervision and interpretation for a peritoneogram. Films are taken of the abdominal cavity from front abdomen and pelvis, with contrast Use a separately reportable code for the procedure. Appendix to back, with an oblique view and a focused (coned material(s), including noncontrast images, down or spot) view. Because an abdominal x-ray if performed, and image postprocessing 74400 usually precedes another diagnostic imaging 74400 Urography (pyelography), intravenous, procedure, it is not coded separately unless Explanation with or without KUB, with or without performed as a separately identifiable