Billing for robotic nephroureterectomy with bladder cuff

Jonathan Rubenstein, MD

I have a question about reporting robotic nephroureterectomy with bladder cuff for ureter or renal pelvis cancer. I perform the entire laparoscopic case robotically for both the nephroureterectomy and the excision of the bladder cuff with a 2-layer bladder closure of the bladder/cystorrhaphy. My former mentor at a different institution advised me to report both CPT 50548 as well as CPT code 51550 for a partial cystectomy since the entire procedure is done robotically and a part of the bladder is removed. However, our billing department questioned whether CPT 51550 should additionally be reported or if CPT 50548 includes bladder cuff. I believe they heard it would only be appropriate to bill the additional code for the bladder cuff/partial cystectomy if that portion is done [via an open incision]. I reassured them that I remove as much bladder with complex bladder closure robotically as I do for the open case. What would you recommend?

As laparoscopic and robotic techniques have evolved over the past several years, we have seen specialty societies and the American Medical Association work through the process of adding new codes and providing guidance for the coding of new services that do not have a CPT code in either Category I or Category III.

Mark Painter

First, CPT convention is specific in its recommendations for selecting a CPT code:

"Select the CPT code of the procedure or service that accurately identifies the procedure or service performed. Do not select a CPT code that merely approximates the procedure or service provided. If no such specific code exists, then report the procedure or service using the appropriate unlisted procedure or service code. When using an unlisted code, any modifying or extenuating circumstances should be adequately and accurately documented in the medical record."¹

You have indicated that you are performing the entire surgery laparoscopically using a robot. AMA coding guidance has been clear that laparoscopic procedures should not be reported with open procedure codes. Therefore, it would not be appropriate to report either CPT code 50234 (Nephrectomy with total ureterectomy and bladder cuff;through same incision) or CPT code 50236 (Nephrectomy with total ureterectomy and bladder cuff; through separate incision) to describe a procedure performed laparoscopically as those are both open codes and should be reported only if the procedure is fully performed open, whether through 1 large midline incision or 2 separate incisions, respectively.

The questions, then, for code selection, become what work is being performed, and what work is already included in the CPT code being reported. For laparoscopic nephroureterectomy, we have heard about a number of techniques [and doctors] who perform the kidney and partial ureter excision laparoscopically yet make an open incision to excise the distal ureter and bladder cuff, and others who perform the entire case laparoscopically. And if done laparoscopically, does this include the removal of the bladder cuff? And is the removal of this part of the bladder the typical service performed?

We see a few options available for reporting the service:

1. Based on the CPT general guidance listed above, there is an argument to be made that closure of the bladder is a part of the total ureterectomy, and the work effort required for a bladder cuff to complete the procedure does not change the description. This is the most likely scenario, as typically a laparoscopic code is made to mimic the associated open code(s) as much as possible; in this case, the available open nephroureterectomy codes (CPT codes 50234 and 50236) specifically state that the bladder cuff is included in the procedure. Based upon the typical performance of a nephroureterectomy and using a laparoscopic code to mimic an open code, it is therefore most likely that even without those specific words in the code descriptor that it is the intent of CPT code 50548 to include removal of the distal ureter even if that includes removing a bladder cuff. Therefore, only CPT 50548 should be reported if the entire procedure is performed laparoscopically, and removal of the distal ureter and bladder cuff are typical and necessary to complete this procedure.

2. However, if one feels that there is significant extra work above and beyond the typical removal of the distal ureter and closure of the bladder cuff, one could add modifier -22 (increased procedural services)to the code. Documentation in the operative note would need to clearly describe what increased service was performed beyond the typical work of the procedure. Payer processing of modifier -22 requires a manual review of the documentation for each case submitted. Manual review by the payer may result in additional payment but is dependent upon the documentation and the interpretation of the documentation by the individual reviewing the service.

3. Another approach, if there is significant extra work, is to additionally report CPT code 51999(Unlisted laparoscopy procedure, bladder) for the bladder cuff based on the partial resection of the bladder and the subsequent repair. Again, this can be considered only if the work performed is above and beyond that of a typical procedure and documented as such. Once again, this would trigger a manual review for payment. Alternatively, the payer could develop a payment pathway for the unlisted code, if needed. The advantage of this option is that the primary portion of the procedure has assigned relative value units and payment, leaving the additional work for separate payment consideration. CPT guidance does allow for use of unlisted in codes in combination with existing CPT codes, as noted below.

"The CPT code set’s instructions to use an unlisted procedure code do not preclude the reporting of an appropriate code that may be found elsewhere in the CPT code set. It may be appropriate to report multiple Category I or Category III codes together to describe the totality of a service rendered for a given patient encounter, provided each code represents a separately reportable service. Similarly, it is appropriate to report an unlisted code together with a Category I or Category III code(s) for the same patient encounter on the same date of service when a separately reportable portion of a provided procedure or service is not described by an existing CPT code(s)."¹

Ultimately, it is best to report CPT 50548 (only) for the performance of a typical laparoscopic nephroureterectomy. One should consider the other options only in medically necessary circumstances and only if/when there is significant extra work beyond a typical service. Manual reviews put reimbursement at the whims of the insurer and will also delay payment. One may argue that it is not fair that another code can be reported with CPT 50548 if the bladder cuff is performed using a separate incision. On the other hand, for those cases in which the distal ureter and the bladder cuff are performed through a separate open approach (50650 [Ureterectomy, with bladder cuff (separate procedure)]) one could also argue that in those cases CPT 50548 should be appended with modifier 52 due to the incomplete removal of the entire ureter without bladder repair of any type. For this combination approach to the procedure, the amount of extra work and risk involved in making an open incision to remove the distal ureter is allowed to be reported separately by some payers. As we have often stated, the system is not always fair or logical.

We recommend that you select [one of] the above options that you feel most accurately reflects the documentation within your medical record. Upon billing the service, you may find that modification of your billing may be required for your specific payer.

REFERENCE

1. American Medical Association. CPT 2024 Professional Edition. American Medical Association; 2024.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.