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).”
Also by the Painters: When can modifier –25 be used with an E/M code?
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.